September 2016

Dear Denti-Cal Provider:

Enclosed is the most recent update of the Medi-Cal Dental Program Provider Handbook (Handbook). The pagesreflect changes made to the Denti-Cal program during the month of September 2016. These changes are indicatedwith a vertical line next to the text.

The following list indicates the pages that have been updated for the Third quarter Handbook release. Previouslyreleased bulletins can be found on the Denti-Cal Provider Bulletins page of the Denti-Cal Web site:http://www.denti-cal.ca.gov/.Remove These PagesLetter to DoctorEntire SectionHow To Use This HandbookEntire SectionSection 12 - Denti-Cal Bulletin IndexEntire Section

Insert These Pages

Entire SectionEntire SectionEntire Section

Thank you for your continual support of the Medi-Cal Dental Program. If you have any questions, please call(800) 423-0507.Sincerely,

DENTI-CALCALIFORNIA MEDI-CAL DENTAL PROGRAM

September 2016

Dear Doctor:We are pleased to provide you with the Medi-Cal Dental Program Provider Handbook (Handbook).The purpose of this Handbook is to give dental care professionals and their staff a concise explanation of billinginstructions and procedures under the California Medi-Cal Dental (Denti-Cal) Program. It is designed to assist youin your continued participation in the Denti-Cal Program.We trust you will find the Handbook useful and that it will be maintained as a working document. Please do nothesitate to visit the Denti-Cal Web site at http://www.denti-cal.ca.gov/ or call upon Denti-Cal for furtherassistance.Sincerely,

PrefaceThis Handbook contains basic information about Denti-Cal. It is designed to provide detailed informationconcerning Denti-Cal policies, procedures and instructions for completing the necessary forms and other relateddocuments.The criteria and policies contained in this Handbook are subject to the provisions of the Welfare and Institutions(W & I) Code and regulations under California Code of Regulations (CCR), Title 22. When changes in these criteriaand/or policies occur, bulletins and revised pages will be issued for purposes of updating the information in thisHandbook.Please call the Denti-Cal toll-free number, (800) 423-0507, with any questions you have regarding the contents ofthis Handbook or participation in the California Medi-Cal Dental Program. Our Provider Services staff will be happyto assist you.Copies of this Handbook, and other valuable information, can be found on the Denti-Cal Web site:http://www.denti-cal.ca.gov/.

How to Use This Handbook

This Handbook is your primary reference for information about the Denti-Cal Program, as well as submission andprocessing of all necessary documents. The Handbook contains detailed instructions for completing Denti-Calclaims, Treatment Authorization Requests, Resubmission Turnaround Documents, Claim Inquiry Forms and otherbilling forms for dental services, and should be consulted before seeking other sources of information.The Handbook is organized into 13 major sections:

The Table of Contents provides an overview of all major sections and subsections in the Handbook.Bulletin information released from December 2015 through September 2016 has been incorporated into theHandbook. Please refer to the Denti-Cal Bulletin Index for the page where the information may be found.

IntroductionProgram BackgroundIn July 1965, two important amendments to theSocial Security Act greatly expanded the scope ofmedical coverage available to much of thepopulation. Title XVIII established the Medicareprogram, and Title XIX created the optional statemedical assistance program known as Medicaid. Thislegislation also provided for the federal governmentto match funds for states electing to implement acomprehensive health care program.In November 1965, legislation was signed toimplement the Title XIX program in the State ofCalifornia, called Medi-Cal. A dental segment of thisprogram was subsequently established. Initially,benefits provided under the California Medi-CalDental (Denti-Cal) Program were approved by theState and paid by Blue Shield of California as fiscalintermediary. Since January 1, 1974, Delta Dental ofCalifornia has administered the Denti-Cal Program forthe State of California, Department of Health CareServices.Over the years, the Denti-Cal program has undergoneseveral changes. Legislation in 1991 brought aboutreduced documentation and prior authorizationrequirements for many common procedures,increased the fees paid to providers for theseservices, and expanded outreach activities topromote greater access to dental care for all Medi-Calbeneficiaries. The Denti-Cal program has also seenthe creation of an orthodontic benefits program forbeneficiaries with handicapping malocclusion, cleftpalate and craniofacial anomalies. The scope ofavailable services for children was widened with theaddition of dental sealants as a covered benefit.Effective July 1, 2009, Assembly Bill X3 5 (Evans,Chapter 20, Statutes of 2009-10) added Section14131.10 to the Welfare and Institutions Code,eliminated most dental services for adults 21 yearsand older. Dental services that are still benefits foradults are: Federally Required Adult Dental Services(FRADS), dental services for pregnant beneficiaries fortreatment of conditions that might complicate thepregnancy, dental services that are necessary aseither a condition precedent to other medicalThird Quarter, 2016

Program ObjectivesThe primary objective of the Denti-Cal Program is tocreate a better dental care system and increase thequality of services available to those individuals andfamilies who rely on public assistance to help meettheir health care needs. Through expandingparticipation by the dental community and efficient,cost-effective administration of the Denti-CalProgram, the goal to provide quality dental care toMedi-Cal beneficiaries continues to be achieved.

RegulationsDenti-Cal is governed by policies subject to the lawsand regulations of the Welfare and Institutions (W &I) Code, the California Code of Regulations (CCR), Title22, and the California Business and Professions Code Dental Practice Act. For additional information, visitthese web sites:

Program OverviewProvider Participation in the CaliforniaMedi-Cal Dental (Denti-Cal) ProgramTo receive payment for dental services rendered toMedi-Cal beneficiaries, prospective providers mustapply and be approved by Denti-Cal to participate inthe Denti-Cal Program, the details of which are foundin Section 3: Enrollment Requirements of thisHandbook. When a provider is enrolled in the DentiCal program, Denti-Cal sends the provider a letterconfirming the providers enrollment effective date.Denti-Cal will not pay for services until the provider isactively enrolled in the Denti-Cal Program.

Compliance in the Denti-Cal Program

Comply with Title VI of the Civil Rights Act of

1964 (PL 88-352), the Americans with DisabilitiesAct of 1990, Section 504 of the Rehabilitation Actof 1973, and all requirements imposed by theDepartment of Health and Human Services(DHHS) (45 CFR Part 80), which states that noperson in the United States shall, on the groundof race, color, religion, sex, age, disability, ornational origin, be excluded from participation in,be denied the benefits of, or be otherwisesubjected to discrimination under any programor activity for which the applicant receives statefinancial assistance from the Department.Additionally, providers must comply withCalifornia Department of Corporations laws andregulations, which forbid discrimination based onmarital status or sexual orientation (Rule1300.67.10, California Code of Regulations).Keep and maintain all records disclosing the typeand extent of services provided to a beneficiaryfor a period of three years from when the servicewas rendered (W & I Code, Sections 14124.1 and14124.2).Provide all pertinent records to any authorizedrepresentative of the state or federalgovernment concerning services rendered to a

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4.

5.

beneficiary (California Code of Regulations (CCR),

Title 22, Section 51476(g)).Not bill or collect any form of reimbursementfrom beneficiaries for services included in theDenti-Cal program scope of benefits, with theexception of Share of Cost (California Code ofRegulations (CCR), Title 22, Section 51002).Certify: the services listed on the TreatmentAuthorization Request (TAR)/Claim formhave been provided to the beneficiary eitherby the provider or another person eligibleunder the Medi-Cal program to provide suchservices. Such person(s) must be designatedon the treatment form. the services were necessary to the health ofthe beneficiary. that he or she understands payment forservices rendered will be made from federaland/or state funds and that any falsificationor concealment of a material fact may beprosecuted under Federal and/or State laws.

Failure to comply with Dent-Cal program

requirements will result in corrective actions. Pleasesee Section 8: Fraud, Abuse and Quality of Care ofthis Handbook for more information.

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Out-of-State CoverageOut-of-state providers who wish to be reimbursed byDenti-Cal for services provided to California Medi-Calbeneficiaries are subject to specific regulations underCalifornia Code of Regulations (CCR), Title 22, Section51006, Out-of-State Coverage. The regulations state:(a) Necessary out-of-state medical care, within thelimits of the program, is covered only under thefollowing conditions:(1) When an emergency arises from accident,injury or illness; or(2) Where the health of the individual would beendangered if care and services arepostponed until it is feasible that he returnto California; or(3) Where the health of the individual would beendangered if he undertook travel to returnto California; or(4) When it is customary practice in bordercommunities for residents to use medicalresources in adjacent areas outside theState; or(5) When an out-of-state treatment plan hasbeen proposed by the beneficiarysattending physician and the proposed planhas been received, reviewed and authorizedby the Department before the services areprovided. The Department may authorizesuch out-of-state treatment plans onlywhen the proposed treatment is notavailable from resources and facilitieswithin the State.(6) Prior authorization is required for all out-ofstate services, except:(A) Emergency services as defined in Section51056.(B) Services provided in border areasadjacent to California where it iscustomary practice for Californiaresidents to avail themselves of suchservices. Under these circumstances,program controls and limitations are thesame as for services from providerswithin the state.Program OverviewPage 2-2

(b) No services are covered outside the United

States, except for emergency services requiringhospitalization in Canada or Mexico.More information on Out-of-State Coverage is foundon the Administrative Law Web site:http://www.oal.ca.gov/.

Written CorrespondenceMost provider inquiries can be answered by using theautomated system or operator-assisted options thatare available through the toll-free telephone line. Forprotection and confidentiality, Denti-Cal requires thatcertain inquiries and requests be made throughwritten correspondence only. The types of inquiriesand requests that must be sent to Denti-Cal in writinginclude:

a change or correction to a providers

name/address or other informationconcerning a dental practice;a request for a detailed printout of aproviders financial information, such asyear-to-date earnings;a change in electronic funds transferinformation, such as a different bankinginstitution or new account number;a request to stop payment of or reissue alost or stolen Denti-Cal payment check.

All written inquiries and requests should contain at a

Written correspondence should also include any

other specific information that pertains to an inquiryor request.Direct all written correspondence to:Denti-CalAttn: [Name of Department]PO Box 15609Sacramento, CA 95852-0609Upon receipt of written correspondence, the providerwill receive acknowledgement that the request hasbeen received by Denti-Cal and is being processed.Third Quarter, 2016

Suspended and Ineligible Providers

Billing providers who submit claims for servicesprovided by a rendering provider suspended fromparticipation in the Denti-Cal Program are alsosubject to suspension from the Program.Welfare and Institutions (W & I) Code, 14043.61(a)states that a provider shall be subject to suspensionif claims for payment are submitted under anyprovider number used by the provider to obtainreimbursement from the Medi-Cal program for theservices, goods, supplies, or merchandise provided,directly, or indirectly, to a Medi-Cal beneficiary, by anindividual or entity that is suspended, excluded, orotherwise ineligible because of a sanction to receive,directly or indirectly, reimbursement from the MediCal program and the individual or entity is listed oneither the Suspended and Ineligible Provider List,orany list is published by the federal Office of InspectorGeneral regarding the suspension or exclusion ofindividuals or entities from the federal Medicare andMedicaid programs, to identify suspended, excluded,or otherwise ineligible providers.The List of Excluded Individuals/Entities compiled bythe Office of Inspector General is available online at:http://exclusions.oig.hhs.gov.

Enrollment Denied for Failure to Disclose

Fraud or Abuse, or Failure to RemediateDeficienciesPer Assembly Bill 1226 (Chaptered October 14, 2007,amending Sections 14043.1, 14043.26, and 14043.65of the Welfare and Institutions Code):A provider whose application for enrollment is deniedfor failure to disclose fraud or abuse, or failure toremediate deficiencies after Department of HealthCare Services (DHCS) has conducted additionalinspections, may not reapply for a period of threeyears from the date the application is denied. Threeyear debarment from the Medi-Cal program wouldbegin on the date of the denial notice.Applicants are allowed 60 days to resubmit theircorrected application packages when DHCS returns itdeficient.

Telephone Service Center Representatives are

available Monday through Friday between 8:00 a.m.and 5:00 p.m., excluding holidays. Providers areadvised to call between 8:00 a.m. and 9:30 a.m., and12:00 noon and 1:00 p.m., when calls are at theirlowest level.Hours of operation and additional information for theInteractive Voice Response (IVR) system can be foundin Section 4: Treating Beneficiaries of thisHandbook.In order for Denti-Cal to give the best possible serviceand assistance, please use the Denti-Cal Provider tollfree number: (800) 423-0507.

If an office receives inquiries from beneficiaries,

please refer them to the Denti-Cal BeneficiaryServices toll-free number: (800) 322-6384The Beneficiary Services toll-free lines are availablefrom 8:00 a.m. to 5:00 p.m. Monday through Friday,excluding holidays.Either beneficiaries or their authorizedrepresentatives may use this toll-free number.Beneficiary representatives must have thebeneficiarys name, BIC or CIN and a signed Releaseof Information form on file with Denti-Cal in order toreceive information from the Denti-Cal program.The following services are available from the DentiCal program by Beneficiary Services toll-freetelephone operators:1.2.3.4.5.6.

A referral service to dentists who accept new

Denti-Cal beneficiariesAssistance with scheduling and reschedulingClinical Screening appointmentsInformation about SOC and copaymentrequirements of the Denti-Cal ProgramGeneral inquiriesComplaints and grievancesInformation about denied, modified or deferredTreatment Authorization Requests (TARs)

Inquiries that cannot be answered immediately will

be routed to a telephone inquiry specialist. Thequestion will be answered by mail within 10 days ofthe receipt of the original telephone call.

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Contact Listings for Denti-Cal

Denti-Cal Program - Contact the Denti-Cal Program for questions related to payments of claims and/orauthorizations of Treatment Authorization Requests (TARs).Provider Toll-Free Line

Beneficiary State Hearings/To Withdraw from a State Hearing

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Internet Access and Web Sites

The Denti-Cal web site (http://www.dentical.ca.gov/) now meets increased usability andaccessibility standards, and has been improved toallow for faster navigation to important topics andprovider resources. A new search engine makesfinding information fast and easy.Both the Denti-Cal and Medi-Cal Web sites(http://www.medi-cal.ca.gov/) are available 24hours/day, seven days/week. The latest versions offree browsers and other tools, such as AdobeAcrobat, may be accessed through the Web sitestoolbox link. Both Web sites provide links to othersites with useful and related information.The Denti-Cal Web site provides access to:

The Medi-Cal Web site allows providers to:

access eligibilityperform Share of Cost (SOC) transactions

More information about SOC can be found in

Section 4: Treating Beneficiaries of this Handbook.

E-MailProviders can now subscribe to the Denti-CalProvider E-mail List to receive updates related to theDenti-Cal program. A registration form is availableon the Denti-Cal website. Providers may unsubscribefrom the e-mail list at any time.

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Training ProgramDenti-Cal offers an extensive training program thathas been designed to meet the needs of both newand experienced providers and their staffs.

SeminarsDenti-Cal conducts basic and advanced seminarsstatewide. Seminar attendees receive the mostcurrent information on all aspects of the Denti-CalProgram. Basic seminars address general programpurpose, goals, policies and procedures; provideinstructions for the correct use of standard billingforms; and explain the reference materials andsupport services available to Denti-Cal providers. Theexpanded format of the advanced seminars offers indepth information on topics such as Medi-CalIdentification Cards; dental criteria; radiograph anddocumentation requirements; processing codes; andother topics of specific concern to Denti-Calproviders.

workshops, making reservations well in advance is

recommended. If unable to keep the reservation,please notify Denti-Cal promptly. Space is limited andno-shows prevent others from being able to attend.Seminar schedules are available on the Denti-Cal Website: http://www.denti-cal.ca.gov/.

On-Site VisitsProviders needing assistance may request an on-sitevisit by a Provider Relations Representative byphoning the Denti-Cal Telephone Service Center:(800) 423-0507. This personal attention is offered tohelp the provider and office staff better understandDenti-Cal policies and procedures to easily meetprogram requirements.

In addition to the regular basic and advanced

seminars scheduled each quarter, Denti-Cal conductsworkshops and orthodontic specialty seminarsthroughout the year. The uniquely designedworkshops give inexperienced billing staff a handson opportunity to learn about the Denti-Cal programand practice their newly acquired skills. Specializedtraining seminars have been developed fororthodontists who participate in the Denti-CalOrthodontic Services Program; these intensifiedsessions cover all aspects of the Denti-Cal orthodonticprogram, including enrollment and certification,completion of billing forms, billing procedures andcriteria and policies specific to the provision of DentiCal orthodontic services.Each Denti-Cal training seminar is conducted by anexperienced, qualified instructor.Continuing education credits for all seminars areoffered to dentists and registered or certified dentalassistants and hygienists. Denti-Cal training seminarsare offered free of charge at convenient times andlocations.Although there are no prerequisites for attendance atany type of seminar, in order for Denti-Cal tocontinue offering free provider training seminars andThird Quarter, 2016

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Provider First-Level Appeals

Provider Appeals Process

The three separate, specific procedures for askingDenti-Cal to reevaluate/appeal the denial ormodification of a claim payment or a TARauthorization are as follows:1.2.3.

Submitting a Claim Inquiry Form (CIF)

Reevaluation of a Notice of Authorization (NOA)FirstLevel appeal

To find out why payment of a claim was disallowed or

to furnish additional information to Denti-Cal forreconsideration of a payment denial or modification,the provider should begin by submitting the ClaimInquiry Form (CIF) within six calendar months of theExplanation of Benefits (EOB) date. Please refer toSection 6: Forms of this Handbook for guidelines forsubmitting a CIF. Check the box on the CIF markedCLAIM REEVALUATION ONLY. Remember to send aseparate CIF for each inquiry.Use the Notice of Authorization (NOA) to request asingle reevaluation of modified or disallowedprocedures on a TAR. Check the Reevaluation isRequested box in the upper right corner of the NOA.Do not sign the NOA when requesting reevaluation.Include any additional documentation forreconsideration and return the NOA to Denti-Cal.Reevaluations may be requested only once. InSection 6: Forms of this Handbook, the completeprocedures is listed for requesting reevaluation of aTAR using the NOA.If upon reconsideration Denti-Cal upholds the originaldecision to disallow payment of the claim orauthorization of treatment, the provider may requestan appeal. In accordance with Title 22, Section 51015,of the California Code of Regulations (CCR), Denti-Calhas established an appeals procedure to be used byproviders with complaints or grievances concerningthe processing of Denti-Cal TAR/Claim forms forpayment. The following procedures should be usedby dentists to appeal the denial or modification of aTAR or claim for payment of services provided underthe Denti-Cal Program:

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1.

2.3.

4.5.

The provider must submit the appeal by letter to

Denti-Cal within 90 days of the EOB denial date.Do not use CIFs for this purpose.The letter must specifically request a first-levelappeal.Send all information and copies to justify therequest. Include all documentation andradiographs.The appeal should clearly identify the claim orTAR involved and describe the disputed action.First-level appeals should be directed to:Denti-CalAttn: Provider First-Level AppealsPO Box 13898Sacramento, CA 95853-4898

Denti-Cal will acknowledge the written complaint or

grievance within 21 calendar days of receipt. Thecomplaint or grievance will be reviewed by Denti-CalProvider Services, and a report of the findings andreasons for the conclusions will be sent to theprovider within 30 days of the receipt of thecomplaint or grievance. If review by Provider Servicesdetermines it necessary, the case may be referred toDenti-Cal Professional Review.If the complaint or grievance is referred to Denti-CalProfessional Review, the provider will be notified thatthe referral has been made and a final determinationmay require up to 60 days from the originalacknowledgement of the receipt of the complaint orgrievance. Professional Review will make itsevaluation and send findings and recommendationsto the provider within 30 days of the date the casewas referred to Professional Review.The provider should keep copies of all documentsrelated to the first-level appeal.Under Title 22 regulations, a Denti-Cal provider whois dissatisfied with the first-level appeal decision maythen use the judicial process to resolve the complaint.In compliance with Section 14104.5 of the Welfareand Institutions Code, the provider must seekjudicial remedy no later than one year afterreceiving notice of the decision of the First LevelAppeal.

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Health Insurance Portability and

Accountability Act (HIPAA) and the NationalProvider Identifier (NPI)The Administrative Simplification provisions of theHealth Insurance Portability and Accountability Act of1996 (HIPAA) mandated the adoption of standardunique identifiers for health care providers, as well asthe adoption of standard unique identifiers for healthplans. The purpose of these provisions is to improvethe efficiency and effectiveness of the electronictransmission of health information. The Centers forMedicare & Medicaid Services (CMS) has developedthe National Plan and Provider Enumeration System(NPPES) to assign these unique identifiers. NPPEScollects identifying information on health careproviders and assigns each a unique NationalProvider Identifier (NPI) number.The NPI is a unique 10-digit number, used across thecountry to identify providers to health care partners,regardless of type of practice or location. All publicand private health plans are required by HIPAA toreceive/submit the NPI as the only provider identifierin all electronic transactions.It is required for use in all HIPAA transactions:

health care claims

Information on how to apply for an NPI can be found

here: https://nppes.cms.hhs.gov.

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Registering NPIsAll NPIs (both billing and rendering providers) mustbe registered with Denti-Cal in order to ensureappropriate payment of claims in a timely manner.Providers may register their NPIs through one ofthree options:1.2.3.

Submitting a hardcopy registration form

Rendering providers who have not submitted a Social

Security Number to Denti-Cal at the time ofenrollment will not be able to register using theDenti-Cal Web site. Such providers will need toregister using the Denti-Cal NPI Registration Form(DHCS 6218) found on the Denti-Cal Web site:http://www.denti-cal.ca.gov/.

Freedom of Information Act (FOIA)Disclosable Data

NPPES health care provider data that are disclosableunder the Freedom of Information Act (FOIA) will bedisclosed to the public by the Centers for Medicare &Medicaid Services (CMS). In accordance with the eFOIA Amendments, CMS has these data via theInternet. Data is available in two forms:

A query-only database, known as the NPI

registry.A downloadable file.

For more information on FOIA visit:

http://www.cms.hhs.gov/aboutwebsite/04_FOIA.asp.

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Electronic Data Interchange (EDI)

Electronic Data Interchange (EDI) is the computer-tocomputer transfer of transactions and information.Providers are encouraged to submit claimselectronically for improved productivity and costefficiency.EDI enrollment and other important EDI informationcan be obtained by:

Enrollment requirements for EDI can be found in

Section 3: Enrollment Requirements of thisHandbook.Providers using EDI for claims submissions are stillrequired to provide radiographs and otherattachments to Denti-Cal. They can be sent either bymail or digitally through a certified electronicattachment vendor.

Digitized ImagesIn conjunction with claims and TARs submittedelectronically, Denti-Cal now accepts digitizedradiographs and attachments submitted throughelectronic attachment vendors National ElectronicAttachment, Inc. (NEA), National Information Services(NIS), and Tesia Clearinghouse, LLC.Note: Providers must be enrolled in EDI to submitdocuments electronically prior to submitting digitizedimages. For more information see Section 3:Enrollment Requirements of this Handbook.

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Overview of TAR and Claim Processing

In administering the Denti-Cal Program, Denti-Calsprimary function is to process TARs and Claimssubmitted by providers for dental services performedfor Medi-Cal recipients. It is the intent of Denti-Cal toprocess TARs and Claims as quickly and efficiently aspossible. A description of the processing workflow isoffered to promote a better understanding of theDenti-Cal automated claims processing system.

Document Control Number (DCN)

All incoming documents are received and sorted inthe Denti-Cal mail room. TARs and Claims areseparated from other incoming documents, includinggeneral correspondence, and assigned a DocumentControl Number (DCN).The DCN is a unique number containing 11 digits inthe following format:14 059 1 000 01The first five digits of the DCN represent the Juliandate of receipt. In the example shown above,14designates the year, and 059 designates thefifty-ninth day of that year. The sixth digit, 1,identifies the type of document: 1 = TAR/Claim form.The remaining five digits of the DCN represent thesequential number assigned to the document. Thus,the document assigned the DCN shown in theexample above would be the first TAR or Claimreceived by Denti-Cal on the fifty-ninth day of 2014 orFebruary 28, 2014.TARs and Claims plus any attachments are thenscanned, batched, and forwarded to Data Entry,where pertinent data from the forms is entered intothe automated claims processing system.

TAR/Claim AdjudicationInformation on a TAR or Claim is audited via a seriesof manual and automated transactions to determinewhether the services listed should be approved,modified or disallowed. If the claim data isdetermined to be satisfactory, the result is payment,with the issuance of an EOB and a check.If the TAR data is determined to be satisfactory, theresult is authorization of treatment, with the issuanceof a NOA.If the information submitted on the TAR or Claim isnot sufficient, the document is held for furthermanual review until a resolution can be concluded. Insome instances, more information may be requiredto make a determination. Denti-Cal will issue aResubmission Turnaround Document (RTD) torequest additional information from the provider.

RadiographsRadiographs should be taken only for clinical reasonsas determined by the beneficiarys dentist.Radiographs are part of the beneficiarys clinicalrecord and the original images should be retained bythe dentist. Originals should not be used to fulfillrequests made by patients or third parties for copiesof records.Radiographs should be taken only for clinical reasonsas determined by the beneficiarys dentist.Radiographs are part of the beneficiarys clinicalrecord and the original images should be retained bythe dentist. Originals should not be used to fulfillrequests made by patients or third parties for copiesof records.Radiographs and photographs will not be returned.

Edits and Audits

After data from the TAR or Claim is scanned into thesystem, the information is automatically edited forerrors. Errors are highlighted on a display screen, andthe data entry operator validates the informationentered against the scanned image. When necessarycorrections are made and the operator confirms thatthe information scanned is correct, the systemprompts the operator as to the proper disposition ofthe TAR or Claim.Third Quarter, 2016

OrthodonticsD8080, D8210, D8220, D8660, D8670, D8680, D8999(non-emergency)Adjunctive ServicesD9220, D9221, D9241, D9242, D9950, D9952, D9999(non-emergency)Dental services provided to patients in hospitals,skilled nursing facilities, and intermediate carefacilities are covered under the Denti-Cal Programonly following prior authorization of each nonemergency and non-diagnostic dental service (Section51307(f)(3), Title 22, California Code of Regulations).Emergency services may be performed onconvalescent patients without prior authorization forthe alleviation of pain or treatment of an acute dentalcondition. However, the provider must submit clinicalinformation with the claim describing thebeneficiarys condition and the reason the emergencyservices were necessary.The Denti-Cal Program, within the Department, andCalifornia Code of Regulations (CCR), Title 22, Section51455, state that prior authorization may be requiredof any or all providers for any or all covered benefitsof the program except those services specificallyexempted by Section 51056(a) and (b). These priorauthorization requirements do not change when thebeneficiary has other dental coverage; the providershould submit for prior authorization and indicate theprimary carrier. No verbal authorization will begranted by Denti-Cal. Denti-Cal reserves the right torequire prior authorization in accordance with theseguidelines.

Election of Prior Authorization

If a provider chooses to submit a TAR for services thatdo not normally require prior authorization, Denti-Calmay not review these procedures. However, theseservices may be reviewed if they are submitted aspart of a total treatment plan. When a providerreceives a NOA for procedures on a TAR that do notnormally require prior authorization, the NOA is not aguarantee that these procedures have beenapproved. (Refer to Section 7: Codes, AdjudicationReason Codes 355A, 355B, and 355C.)

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If a provider elects to have any proposed treatment

plan prior authorized, all provisions relating to priorauthorization for all services listed apply.

Non-Transfer of Prior Authorization

Prior authorization is not transferable from oneprovider to another. If for some reason the providerwho received authorization is unable to complete theservice or the beneficiary wishes to go to anotherprovider, another provider cannot perform theservice until a new treatment plan is authorizedunder his/her own provider number.To expedite processing of a TAR with a change ofprovider, submit a new TAR with an attachedstatement from the beneficiary indicating a change ofprovider.

Retroactive Prior Authorization

as members of the programs Quality Assurance

Committee, serve as impartial observers to examinepatients and report their objective clinical findings.Denti-Cal utilizes these observations as additionalinformation to help in making a final determination ofmedical necessity or the appropriateness and/orquality of care.Screening protocol dictates that the Clinical ScreeningDentist is not allowed to discuss their clinicalobservations with providers, patients, or any thirdparty. In addition, providers or the beneficiarysrepresentatives are not allowed to accompany thebeneficiary to a screening. To ensure attendance, it isalso recommended that providers fully discussproposed treatment with their patients before aclinical screening appointment. Failure to do so mayresult in a potential delay or denial of treatment.

Title 22, Section 51003, State of California Code of

Regulations (CCR) allows for the retroactive approvalof prior authorization under the following conditions:

When certification of eligibility was delayed

by the county social services office;When beneficiarys other dental coveragedenied payment of a claim for services;When the required service could not bedelayed;When a beneficiary does not identifyhimself/herself to the provider as a Medi-Calbeneficiary through deliberate concealmentor because of physical or mental incapacityto identify himself/herself. The providermust submit in writing that concealmentoccurred, and the submission of the TARmust be within 60 days of the date theprovider certifies he/she was made aware ofthe beneficiarys eligibility.

Clinical ScreeningDuring the processing of the TAR, Denti-Cal maydecide to further evaluate the beneficiary andschedule a clinical screening appointment.If this occurs, the dental office will receive a letternotifying them that a screening will take place andthe beneficiary will be sent a screening notificationappointment letter. Clinical Screening Dentists, actingProgram OverviewPage 2-20

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Billing and Payment Policies

(2) To bill a long-term care patient or

representative for the amount of the patientsshare of the cost; or

Billing BeneficiariesProviders may not submit a claim to, or demand orotherwise collect reimbursement from, a Medi-Calbeneficiary, or from other persons on behalf of thebeneficiary, for any service (other than Share of Cost).Section 51002 of Title 22 of the California Code ofRegulations specifically prohibits billing or collectingfrom Medi-Cal beneficiaries for services included inthe Denti-Cal Program scope of benefits, except forthose patients who have a fiscal liability to obtainand/or maintain eligibility requirements.In addition, Title 42, Volume 3, of the Code of FederalRegulations, reads as follows:Section 447.15 Acceptance of State payment aspayment in full.A State plan must provide that the Medicaidagency must limit participation in the Medicaidprogram to providers who accept, as payment infull, the amounts paid by the agency plus anydeductible, coinsurance or copayment required bythe plan to be paid by the individual. However, theprovider may not deny services to any eligibleindividual on account of the individuals inability topay the cost sharing amount imposed by the planin accordance with Sec. 431.55(g) or Sec. 447.53.The previous sentence does not apply to anindividual who is able to pay. An individualsinability to pay does not eliminate his or herliability for the cost sharing charge.Finally, Welfare & Institutions Code reads:14107.3 Any person who knowingly and willfullycharges, solicits, accepts, or receives, in addition toany amount payable under this chapter, any gift,money, contribution, donation, or otherconsideration as a precondition to providingservices or merchandise to a Medi-Cal beneficiaryfor any service or merchandise in the Medi-Calsprogram under this chapter or Chapter 8(commencing with Section 14200), except either:(1) To collect payments due under a contractual orlegal entitlement pursuant to subdivision (b) ofSection 14000; orThird Quarter, 2016

(3) As provided under Section 14019.3, is

punishable under a first conviction byimprisonment in the county jail for not longer thanone year or state prison, or by a fine not to exceedten thousand dollars ($10,000), or both suchimprisonment and fine. A second or subsequentconviction shall be punishable by imprisonment inthe state prison.This clause means that a provider may not bill boththe beneficiary and the program for the same DentiCal procedure. If the provider submits a claim toDenti-Cal, he/she cant bill the beneficiary for thedifference between Denti-Cals Schedule of MaximumAllowances (SMA) and the providers usual,customary, and reasonable (UCR) fee.If Medi-Cal eligibility is verified, the provider may nottreat the beneficiary as a private-pay beneficiary toavoid billing Denti-Cal, obtaining prior authorization(when necessary) or complying with any otherprogram requirement. In addition, upon obtainingeligibility verification, the provider cannot bill thebeneficiary for all or part of the charge of a Medi-Calcovered service except to collect the Medi-Calcopayment or share of cost. Providers cannot billbeneficiaries for private insurance cost-sharingamounts such as deductibles, co-insurance orcopayments.This clause means that once a provider has checked abeneficiarys eligibility, or has submitted a claim orTAR for services, then that provider has agreed toaccept that beneficiary as a Denti-Cal beneficiary andcant later decide to not accept the beneficiary fortreatment to avoid pre-authorization requirement orhaving to accept Denti-Cal fees. The provider alsoagrees not to charge the beneficiary for all or part ofany treatment that has been deemed by Denti-Cal tobe a covered benefit.A provider and beneficiary may enter into a privateagreement under the following scenarios:a.

The provider and beneficiary have agreed to

have specific dental treatment performedoutside of the Denti-Cal program. The providerProgram OverviewPage 2-21

must have not verified the beneficiarys eligibility

or submitted any TAR or claim to Denti-Cal forthe current phase of treatment.Or:b.

The provider has submitted a specific procedure

on a TAR or claim to Denti-Cal that wassubsequently denied on the basis that it waseither not a benefit under Denti-Cals scope ofbenefits or it was denied because it did not meetthe criteria or time/frequency limitations for thespecific procedure. Procedures that have beendenied for technical or administrative reasons,such as failure to respond to ResubmissionTurnaround Documents (RTDs), inadequateradiograph submission, signatures, or that theprocedure is included in a global procedurebilled, cannot be billed to the beneficiary underany circumstances.

Providers should establish written contracts with

beneficiaries before any non-reimbursed Denti-Caltreatment is rendered. They should also secure theproper Denti-Cal denial if applicable.Providers cannot bill a Denti-Cal beneficiary forbroken appointments (42 CFR 447.15 and SSA 1902(a)(19).When beneficiaries request copies of records and/orradiographs, providers can charge them a reasonablefee for duplication, but only when they have thesame policy for their private patients.Providers may only bill beneficiaries their UCR fees ifthe $1,800 limit per calendar year for beneficiaryservices (dental cap) has been met and nothing hasbeen paid on a procedure.Providers may not bill beneficiaries when theprogram has paid any amount on a specific procedureas the result of the beneficiary cap being met. Thispartial payment on a procedure must be consideredpayment in full.

Beneficiary Reimbursements

periods: 1) the 90-day period prior to the month of

application for Denti-Cal; 2) the period after anapplication is submitted but prior to the issuance ofthe beneficiarys Medi-Cal card; and 3) after issuanceof the beneficiarys Medi-Cal card for excess copayments (i.e., co-payments that should not havebeen charged to the beneficiary).By law, a Denti-Cal provider must reimburse abeneficiary for a claim if the beneficiary providesproof of eligibility for the time period during whichthe medically necessary covered service wasrendered (and for which the beneficiary paid).Evidence of the reimbursement paid by the providerto the beneficiary should be submitted to the DentiCal program as a claim with the appropriatedocumentation to indicate that Denti-Cal eligibilitywas recently disclosed. The Department will allow theprovider a timeliness override in order to bill DentiCal for the repaid services. If the provider does notreimburse the beneficiary, the beneficiary maycontact the Department, inform the Department ofthe providers refusal to reimburse, and then submita request for reimbursement directly to theDepartment. In this case, the Department will contactthe provider and request that the provider reimbursethe beneficiary. Should the provider refuse tocooperate, the Department will reimburse thebeneficiary for valid claims and recoup the paymentfrom the provider. Additional sanctions may beimposed on the provider such as those set forth inWelfare and Institutions Code Section 14019.3.

Not a Benefit/GlobalDental or medical health care services that are notcovered by the Medi-Cal program are deemed not abenefit.Global procedures are those procedures that areperformed in conjunction with, and as part of,another associated procedure. Global procedures arenot separately payable from the associatedprocedure.

In accordance with Welfare and Institutions Code

Section 14019.3, a Denti-Cal provider is required toreimburse a Denti-Cal beneficiary who paid for amedically necessary covered service rendered by theprovider during any of the following three timeProgram OverviewPage 2-22

Third Quarter, 2016

Dental Materials of Choice

The Denti-Cal Program wants all providers tounderstand the important distinction between abeneficiarys entitlement to a medically necessarycovered dental service and your professionaljudgment of which dental material is used to performthe service.In general, a Denti-Cal beneficiary is entitled tocovered services that are medically necessary. Thechoice of dental material used to provide a specificservice lies within the scope of the professionaljudgment of the dentist.Providers may not bill beneficiaries for the differencebetween the Denti-Cal fee for covered benefits andthe UCR fee.

Payment PoliciesDenti-Cal will only pay for the lowest cost procedurethat will correct the dental problem. For example,Denti-Cal cannot allow a porcelain crown when arestoration would correct the dental problem. Adental office cannot charge Denti-Cal more than itcharges a private beneficiary for the servicesperformed. The dental office should list its UCR feeswhen filling out the claim, TAR or NOA, not the SMA.For tax purposes, Denti-Cal uses Form 1099 to reportearnings to the Internal Revenue Service (IRS) foreach billing provider who has received payment fromDenti-Cal during the year. Federal law requires thatDenti-Cal mail 1099 forms by January 31 of each yearto reflect earnings from January 1 through December31 of the previous year.It is the providers responsibility to make certainDenti-Cal has the correct billing provider name,address and Taxpayer Identification Number (TIN) orSocial Security Number (SSN) that correspond exactlyto the information the IRS has on file. If thisinformation does not correspond exactly, Denti-Cal isrequired by law to apply a 28 percent withholding toall future payments made to the billing provider. Toverify how tax information is registered with the IRS,please refer to the preprinted label on IRS Form 941,Employers Quarterly Federal Tax Return, or anyother IRS-certified document. The provider may alsocontact the IRS to verify how a business name andTIN or SSN are recorded.Third Quarter, 2016

If a provider does not receive the 1099 form, or if the

tax or earnings information is incorrect, pleasecontact Denti-Cal at (800) 423-0507 for theappropriate procedures for reissuing a correct 1099form.

Assistant SurgeonsAssistant surgeons should bill Denti-Cal usingProcedure D6199/D7999 (as applicable) and may bepaid 20% of the surgical fee paid to the primarysurgeon (dentist or physician) provided the followingis submitted with the claim:

The operating report containing the name of

the assistant surgeon;Proof of payment to the primary surgeon.

Surgical fees include major maxillofacial and

orthognathic procedures, as well as trauma surgery,and include all associated extractions. All otherprocedures (anesthesia, radiographs, restorations,etc.) performed on the same date of service as thesurgical procedure including bedside visits andhospital care are not considered in thedeterminations of the surgical fee and are notpayable to assistant surgeons.

Providing and Billing for

Anesthesia ServicesPrior Authorization is required for general anesthesia(GA) and intravenous (IV) sedation. A TAR can onlybe requested from an enrolled Denti-Cal provider.The anesthesiologist may submit a TAR if they areenrolled as a billing provider. If an anesthesiologist isnot a billing provider, the billing provider renderingthe dental services may submit the TAR on behalf ofthe anesthesiologist rendering the anesthesia.Additionally, if an anesthesiologist is part of a grouppractice, the group practice may submit a TAR onbehalf of anesthesiologist.Note: Prior authorization is not required for abeneficiary who resides in a state certified skillednursing facility (SNF) or any category of intermediatecare facility (ICF) for the developmentally disabled.The provider must submit a documentation indicatedbelow to justify the medical necessity for anesthesiaservices.Program OverviewPage 2-23

If the provider provides clear medical record

documentation of both number 1 and number 2below, then the patient shall be considered forintravenous sedation or general anesthetic:1.

2.

The following is required to receive payment for

administering general anesthesia or intravenousconscious sedation/analgesia:

Use of local anesthesia to control pain failed or

was not feasible based on the medical needs ofthe patient.Use of conscious sedation, either inhalation ororal, failed or was not feasible based on themedical needs of the patient

If the provider documents any one of numbers 3

through 6 then the patient shall be considered forintravenous sedation or general anesthetic:3.

4.

5.

6.

Use of effective communicative techniques and

immobilization (patient may be dangerous to selfor staff) failed or was not feasible based on themedical needs of the patient.Patient requires extensive dental restorative orsurgical treatment that cannot be renderedunder local anesthesia or conscious sedation.Patient has acute situational anxiety due a lack ofpsychological or emotional maturity that inhibitsthe ability to appropriately respond tocommands in a dental setting.Patient is uncooperative due to certain physicalor mental compromising conditions.

Prior authorization can be waived when Intravenous

Sedation/General Anesthesia is medically necessaryto treat an emergency medical condition. An"emergency medical condition" is defined in Title 22,Division 3, Subdivision 1, Chapter 3, Article 2, Section51056 (b).Billing providers must ensure that all their renderingdental anesthesiologists and dentists providinggeneral anesthesia and intravenous conscioussedation/analgesia are permitted or certified throughthe Dental Board of California prior to enrolling in theDenti-Cal program and prior to treating Medi-Calpatients (B&P Code 1646.1and 1647.19-20).Payments made to billing providers for servicesperformed by their unenrolled rendering providerswill be subject to payment recovery per Title 22,Section 51458.1 (a)(6).

Program OverviewPage 2-24

The rendering provider performing the

general anesthesia must have a valid permitwith the Dental Board of California and thepermit number must be on file with DentiCal.The anesthesia record must be signed by theanesthesiologist performing the anesthesiaprocedure. The rendering provider name onthe anesthesia record must coincide with therendering provider number in field 33 on theclaim for payment.

Tamper-Resistant Prescription Pads

In order for Denti-Cal outpatient drugs to bereimbursable by the federal government, all written,non-electronic prescriptions must be executed ontamper-resistant pads. The tamper-resistantprescription pad requirement applies to over-thecounter drugs, and impacts all dentists and otherproviders who prescribe outpatient drugs.The Centers for Medicare and Medicaid Services(CMS) has issued guidance on this requirement thatcan be found on the Web site:www.cms.hhs.gov/center/intergovernmental.asp.As outlined by CMS, a prescription pad must containat least one of the following three characteristics and,by October 1, 2008, all three characteristics:7.

8.

9.

One or more industry-recognized features

designed to prevent unauthorized copying of acompleted or blank prescription form;One or more industry-recognized featuresdesigned to prevent the erasure or modificationof information written on the prescription by theprescriber; or,One or more industry-recognized featuresdesigned to prevent the use of counterfeitprescription forms.

The National Council for Prescription Drug Programs

(NCPDP) has issued a letter providing additionalinformation as to which tamper-resistant features fallwithin the three characteristics, a copy of which canbe found on the Medi-Cal Web site:www.medi-cal.ca.gov.Third Quarter, 2016

The California-required tamper-resistant prescription

pads for controlled drugs fully meet the federalcompliance requirements. Prescribers areencouraged to use the current pads, and may ordertamper-resistant prescription pads from securityprescription printer companies.Those companies preapproved by the CaliforniaDepartment of Justice and Board of Pharmacy toproduce tamper-resistant prescription pads are listedat the following Web site: www.oag.ca.gov/bne/security_printer_list.php. This directory providesan alphabetical listing of companies and is updated asnew security prescription printers are approved.Providers will need their prescribers state licensenumber and a copy of their DEA Registration whenthey place their order. Other security prescriptionprinter companies are available and may be used asneeded. To comply with California statute, regardlessof how a provider chooses to procure tamperresistant prescription pads for all other written MediCal prescriptions, providers must continue to procuretamper-resistant prescription pads for controlleddrugs from the list of approved security prescriptionprinter companies.

Third Quarter, 2016

Program OverviewPage 2-25

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Program OverviewPage 2-26

Third Quarter, 2016

Time Limitations for Billing

Time limitations for billing services provided underthe Denti-Cal Program are governed by Section 14115of the Welfare and Institutions Code. Claims receivedby Denti-Cal within:

six calendar months after the end of the

month in which the service was performedare considered for full payment (100 percentof the SMA)seven to nine months after the end of themonth in which the service was performedwill be considered for payment at 75 percentof the SMA amount.ten to twelve months after the end of themonth in which the service was performedwill be considered for payment at 50 percentof the SMA amount.

The time limitation for billing will be applied to each

date of service.Denti-Cal may receive and process late claims uponreview of substantiating documentation that justifiesthe late submittal of a claim. The following is a list ofreasons delayed submissions are acceptable whencircumstances are beyond the control of the provider:1.

2.

3.

A beneficiary did not identify himself/herself to a

provider as a Medi-Cal beneficiary at the timeservices were performed. The provider mustsubmit the claim for payment within 60 daysafter the date certified by the provider that thebeneficiary first did identify himself/herself as aMedi-Cal beneficiary. The date so certified on theclaim must be no later than one year after themonth in which services were performed.The maximum time period for submission of aclaim involving other coverage is one year fromthe date of service, to allow sufficient time forthe provider to obtain proof of payment or nonliability of the other insurance carrier.If a delay in submitting a claim for payment wascaused by circumstances beyond the control ofthe provider, Denti-Cal may extend the period ofsubmission to one year from the date of service.Title 22, Section 51008, lists those specificcircumstances which would be considered

Third Quarter, 2016

beyond the control of the provider and under

which such an extension may be granted: delay or error in the certification ordetermination of Medi-Cal eligibility by theState or county; delay in delivering a completed removableappliance when a beneficiary does notreturn in a timely manner for delivery(Section 51470(b) states an undelivered,custom-made prosthesis must be retainedfor no less than one year after the date itwas ordered, and is payable at 80% of theamount after the provider has attempted todeliver the prosthesis to the beneficiary); damage to or destruction of providersbusiness office or records by naturaldisaster, including fire, flood, or earthquake;or circumstances involving such a disasterthat have substantially interfered with thetimely processing of bills; delay of required authorization by Denti-Cal; delay by Denti-Cal in supplying billing formsto the provider; theft, sabotage, or other deliberate, willfulacts by an employee; other circumstances, clearly beyond thecontrol of the provider that have beenreported to the appropriate lawenforcement or fire agency, whereapplicable; special circumstances, such as court or fairhearing decisions.

Program OverviewPage 2-27

Provider Notification of Beneficiary

Request for Reimbursement

Interim PaymentsInterim payments are made to Denti-Cal providers forunpaid claims that have been delayed at least 30 daysdue to Denti-Cal or State errors, or for paid claimsaffected by retroactive changes.A provider may contact Denti-Cal, either bytelephone or in writing, to request interim payment.Denti-Cal will determine if a claim qualifies for interimpayment. If it does not qualify, or if a determinationcannot be made, Denti-Cal must notify the providerby telephone within 24 hours, followed by a writtennotice within two workdays. If Denti-Cal determinesthat a claim does qualify for interim payment, thefindings are forwarded to the State for final approvalor denial of the request.When the State reaches a final decision, it will notifyDenti-Cal.Denti-Cal, in turn, will notify the provider. Once finalapproval of interim payment has been received fromthe State by Denti-Cal, the payment request isprocessed and a check is generated and sent to theprovider.

Retroactive Reimbursement for Medi-Cal

Beneficiaries for Out-of-Pocket ExpensesAs a result of the Conlan v. Shewry court decision, aprocess has been implemented by which beneficiariescan obtain prompt reimbursement of their Denti-Calcovered, out-of-pocket expenses. For questions orinstructions regarding this reimbursement, pleasephone the Conlan Help Desk at (916) 403-2007.

Denti-Cal ResponsibilitiesDenti-Cal responsibilities include the following:

If a beneficiarys request for reimbursement is

validated by Denti-Cal, a letter of request forbeneficiary reimbursement is sent to the provider.This letter must be submitted with the providersclaim for reimbursement.

Provider ResponsibilityUpon receipt of a beneficiary reimbursement letter,providers are expected to reimburse beneficiaries formonies that the beneficiary paid to the provider atthe time of service, then submit a claim to Denti-Cal.Claims will be denied if the beneficiary has not beenreimbursed.

Claim SubmissionProviders must submit claims to Denti-Cal within 60days of the date on the letter as follows:

Third Quarter, 2016

Provider ReimbursementProviders are reimbursed for medically necessaryservices according to the current SMA found inSection 5: Manual of Criteria and Schedule ofMaximum Allowances of this Handbook.To be reimbursed, the provider must have beenenrolled as a Denti-Cal provider on the date ofservice. Providers should contact Denti-Cal at (800)423-0507 or online at http://www.denti-cal.ca.gov/ ifany of the following conditions apply:

Provider was not a Denti-Cal provider on the

date of service but wants to enroll nowProvider is a Denti-Cal provider now, but wasnot enrolled on the date of service andneeds retroactive eligibilityProvider was not a Denti-Cal provider on thedate of service, but wants to temporarilyenroll retroactively in Denti-Cal in order tobill for the Beneficiary ReimbursementProcess claims

Payment for a Medicare covered dental service

does not depend on place of service;hospitalization or non-hospitalization of abeneficiary has no direct bearing on the coverageor exclusion of any given dental procedure.

For information about Medicare enrollment and

billing procedures, please visit the NoridianHealthcare Solutions web site:https://med.noridianmedicare.com/web/jebWhen processing a claim with Medicare coveredservices, Denti-Cal reviews the EOMB submitted withthe claim. The Medicare procedures listed on theEOMB are matched with the Denti-Cal procedureslisted on the claim. Payment calculations are basedon Medicare deductibles, coinsurance and Medi-Calallowable amounts up to the SMA.

If a TAR/Claim is submitted for a Denti-Cal beneficiary

and Field 31 contains any of the procedure codeslisted above, the claim or TAR must be accompaniedby official documentation which clearly shows proofof payment/denial by Medicare or states thebeneficiarys ineligibility. Documentation ofineligibility may be:1.2.3.4.

An Explanation of Medicare Benefits (EOMB)

stating No Part B coverage;An EOMB stating Benefits are exhausted;An official document verifying the beneficiarysalien status;An EOMB or any official document from theSocial Security Administration verifyingbeneficiarys ineligibility for Medicare.

Denti-Cal processes claims and TARs for Medicare

A provider must be enrolled with Medicare to bill

Denti-Cal for Medicare/Medi-Cal crossoverservices.Medicare must be billed for Medicare coveredservices prior to billing Denti-Cal. When billingDenti-Cal, attach the EOMB to the claim form.Approved and paid Medicare dental services donot require prior authorization by Denti-Cal.

Third Quarter, 2016

Program OverviewPage 2-31

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Program OverviewPage 2-32

Third Quarter, 2016

Orthodontic Services Program

The provision of medically necessary orthodonticservices is limited to Medi-Cal and CaliforniaChildrens Services (CCS) eligible individuals under 21years of age by dentists qualified as orthodontistsunder the California Code of Regulations, Title 22,Section 51223(c). For additional information, seeSection 9: Special Programs of this Handbook.

Dental Restorations for Children Under Age

Four and for Developmentally DisabledBeneficiaries of Any AgeSenate Bill (SB) 1403 (Chapter 61, signed July 7,2006), stipulates that For any beneficiary who isunder four years of age, or who, regardless of age,has a developmental disability, as defined insubdivision (a) of [Welfare and Institutions Code]Section 4512, radiographs or photographs thatindicate decay on any tooth surface shall beconsidered sufficient documentation to establish themedical necessity for treatment provided.Claims, NOAs, and CIFs with dates of service on orafter January 1, 2007, and any TAR or reevaluationrequiring review will only require one radiograph orphotograph that demonstrates medical necessity tobe submitted. When the radiograph or photographdemonstrates at least one decayed surface, all of thefillings and prefabricated crowns on that documentwill be allowed, unless the beneficiarys historyindicates the tooth has been previously extracted, arecent filling/prefabricated crown, etc.Providers who are replacing fillings or prefabricatedcrowns that they previously placed must submit acurrent radiograph or photograph of that tooth thatdemonstrates the need for replacement when theapplicable time limitations have not been met.

When no radiographs or photographs are

submitted, or when the single radiograph orphotograph that is submitted is not currentor is non-diagnostic, all fillings andprefabricated crowns on that document willbe denied/disallowed.When there is no decay evident in the singleradiograph or photograph submitted, allrestorations will be denied/disallowed.

Third Quarter, 2016

When a pulpotomy is requested in

conjunction with a filling/prefabricatedcrown, and the filling/prefabricated crown isdenied/disallowed, the pulpotomy will alsobe disallowed.

Children Under Age Four

The beneficiary must be under the age of four at thetime the services were rendered or when the requestfor authorization was reviewed.

Developmentally Disabled (DD)

BeneficiariesSenate Bill (SB) 1403 (Chapter 61, signed July 7,2006), amends Section 14132.88 of the Welfare andInstitutions (W & I) Code in the following ways:Once a provider has established the fact that theirbeneficiary is a client of a Regional Center/Department of Developmental Services, he/ she mustdocument that fact on the document by writing thefollowing Registered Consumer of the Departmentof Developmental Services. No substitute languageor documentation will suffice.When requesting authorization/payment ofprefabricated crowns on permanent teeth for DDpatients, the requirement for arch films will bewaived.

Hospital (Special) Cases

When dental services are provided in an acute caregeneral hospital or a surgicenter, the provider mustdocument the need for hospitalization, e.g.,retardation, physical limitations, age, etc.To request authorization to perform dental-relatedhospital services, providers need to submit a TARwith radiographs/photos and supportingdocumentation to Denti-Cal. Prior authorization isrequired only for the following services in a hospitalsetting: fixed partial dentures, removable prosthetics,and implants.It is not necessary to request prior authorization forservices that do not ordinarily require authorizationfrom the Denti-Cal program, even if the services areProgram OverviewPage 2-33

provided in an outpatient hospital setting. In all cases,

an operating room report or hospital dischargesummary must be submitted with the claim forpayment.

Hospital Inpatient Dental Services

(Overnight or Longer)Inpatient dental services are defined as servicesprovided to beneficiaries residing in hospitals, skillednursing facilities (SNFs), intermediate care facilities(ICFs), and those who are homebound.Dental services provided to patients in hospitals arecovered under the Denti-Cal Program only followingprior authorization of each non-emergency and nondiagnostic dental service (Section 51307(f)(3), Title22, California Code of Regulations). Emergencyservices may be performed on hospital patientswithout prior authorization for the alleviation of painor treatment of an acute dental condition. However,the provider must submit clinical information withthe claim describing the beneficiarys condition andthe reason the emergency services were necessary.Inpatient dental services (hospitals, SNFs, and ICFs)are covered only when provided on the signed orderof the provider responsible for the care of thebeneficiary. A claim for inpatient dental services mustshow verification that the services are to be renderedon the signed order of the admitting physician ordentist.If a Denti-Cal provider needs to perform dentalservices within a hospital inpatient setting, theprovision of the medical support services, e.g.,Operating Room (OR) time, surgical nurse,anesthesiologist, or hospital bed, will depend on howthe Denti-Cal beneficiary receives their Medi-Calmedical services. Denti-Cal beneficiaries may receivetheir medical services through a number of differententities:

Medi-Cal Fee-For-Service (FFS)

Denti-Cal providers should refer to Section 4:

Treating Beneficiaries of this Handbook for

Program OverviewPage 2-34

instructions on how to determine the entity providing

a beneficiarys medical services.Prior authorization is required for each nonemergency and non-diagnostic dental serviceprovided to Denti-Cal beneficiaries in a hospitalinpatient setting where the beneficiarys hospital stayexceeds 24 hours. This authorization must besubmitted on the Medi-Cal Form 50-1 and sentdirectly to this address:Department of Health Care ServicesSan Francisco Medi-Cal Field OfficeP.O. Box 3704San Francisco, CA 94119(415) 904-9600The Medi-Cal Form 50-1 should not be submitted toDenti-Cal as this will only delay the authorization forhospital admission.For more information regarding the Medi-Cal TARfield offices, please review this document:http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/tarfield_m00i00o01o03o04o06o07o08o11a02a04a05a06a07a08p00l00.docIf the beneficiary requires emergency hospitalization,a verbal authorization is not available through theMedi-Cal field office. If the beneficiary is admitted asan emergency case, the provider may indicate in theVerbal Authorization Box on the Medi-Cal Form 50-1,Consultant Not Available (CNA). An alternative is toadmit the beneficiary as an emergency case andsubmit the Medi-Cal Form 50-1 retroactively withinten working days to the Medi-Cal field office.A claim for payment of dental services is submitted toDenti-Cal and must be accompanied by a statementdocumenting the need and reason the emergencyservice was performed. Include a copy of theoperating room report.

For more information about Denti-Cal inpatient and

Homebound Patients (Place of Service 2)

A physicians letter is required when requestingdental services for a beneficiary who cannot leavehis/her private residence due to a medical condition.The physicians letter must be on his/her professionalletterhead with the following informationdocumented:

The beneficiarys specific medical condition

The reason the beneficiary cannot leave theprivate residenceThe length of time the beneficiary will behomebound

Emergency services may be performed on

homebound patients without prior authorization forthe alleviation of pain or treatment of an acute dentalcondition. In addition to the submission requirementsfor each individual procedure, the provider must alsosubmit documentation with the claim describing thebeneficiarys condition and the reason the emergencyservices were necessary. A letter from thebeneficiarys physician, as stated above, must also besubmitted with the claim.

Skilled Nursing and Intermediate Care Facilities

(Place of Service 4 or 5)The California Department of Public Health defines aSkilled nursing facility and Intermediate care facilityas the following:

Providers may use the California Department of

Public Health Web site to verify licensed facilities:http://hfcis.cdph.ca.gov/servicesAndFacilities.aspxAll TARs and claims submitted for patients residing inSNFs or ICFs must include the following:

place of service 04 or 05 (only) must be

indicated regardless of where the dentalservices were or will be performed.facility name, phone number and address,regardless of where the dental services wereor will be performed in Box 34 of the claimor TAR form.when treating residents outside of thefacility, indicate the actual place of service inBox 34.

Mobile Dental Treatment Vans

(Place of Service 8)Mobile dental treatment vans are considered, underDenti-Cal, to be an extension of the providers officeand are subject to all applicable requirements of theprogram.

Hospital Care (Including Surgical Centers)

(Place of Service 6 or 7)In a hospital setting, prior authorization for treatmentincluded in the scope of benefits is not requiredexcept for laboratory processed crowns, fixed partialdentures, and implants. When treatment isperformed without prior authorization (on aprocedure that would normally require priorauthorization), requests for payment must beaccompanied by radiographs, photographs, and anydocumentation to adequately demonstrate themedical necessity. Refer to the individual proceduresfor specific requirements and limitations. In addition,requests for payment must be accompanied by anoperating room report that indicates the amount oftime spent in the operating room suite.

Enrollment RequirementsProvider Application and Disclosure FormsTo receive payment for dental services rendered toMedi-Cal beneficiaries, prospective providers mustapply and be approved by Denti-Cal to participate inthe Denti-Cal Program. When a provider is enrolled inthe Denti-Cal program, Denti-Cal sends the provider aletter confirming the providers enrollment effectivedate. Denti-Cal will not pay for services until theprovider is actively enrolled in the Denti-Cal Program.The Denti-Cal Program utilizes the same applicationsas those used by providers participating in the MediCal Program. A prospective provider must use themost current version of these forms. To obtain acurrent application packet, contact Denti-Cal toll-freeat (800) 423-0507 or visit the Denti-Cal Web site:http://www.denti-cal.ca.gov/WSI/Prov.jsp?fname=ApplicationForms. Failure to submit theappropriate form(s) and supporting documentationwill delay the processing of an application and it willbe returned as incomplete.Applicants who are natural persons licensed orcertificated under the Business and Professions Codeor the Osteopathic or Chiropractic Initiative Acts toprovide health care services, or who are professionalcorporations under subdivision (b) of Section 13401of the Corporations Code, must enroll in the Medi-CalProgram as either individual providers or as renderingproviders in a provider group. This is true even if theperson or the professional corporation meets therequirements to qualify as exempt from cliniclicensure under subdivision (a) or (m) of Section 1206of the Health and Safety Code (see W&I Code Section14043.15(b)(1)).W&I Code Section 14043.26(a)(1) requires aprospective provider not currently enrolled in theMedi-Cal Program or a provider applying forcontinued enrollment to submit a completeapplication package for enrollment, continuedenrollment, or enrollment at a new location or achange in location.

Denti-Cal does not accept application forms with a

revision date prior to 02/08. The forms listed abovewith a revision date of 02/08 or later will beaccepted.Prospective providers must have received a NationalProvider Identifier (NPI) prior to applying to the MediCal Dental Program. This unique identifier is requiredon all Medi-Cal applications.

Rendering Provider Enrollment Process

In accordance with the California Code of Regulations(CCR), Title 22, 51000.31(b), rendering providersmust apply to the Denti-Cal Program by submitting aMedi-Cal Rendering Provider Application/DisclosureStatement/Agreement for Physician/Allied DentalProviders (DHCS 6216, Rev. 2/15) form.Rendering providers must be enrolled in the Denti-Calprogram prior to rendering services to a Denti-Calbeneficiary. Denti-Cal will not pay for services until

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Enrollment RequirementsPage 3-1

the provider is actively enrolled in the Denti-Cal

Program.Enrolled rendering providers in good standing mayjoin existing provider groups or practice at otherlocations without submitting additional applicationsfor each location.Applications may be obtained by contacting theTelephone Service Center at (800) 423-0507, or visitthe Denti-Cal Application Forms section on the DentiCal Web site at: http://www.denti-cal.ca.gov/WSI/Prov.jsp?fname=ApplicationForms.Rendering providers must provide a National ProviderIdentifier (NPI). To obtain an NPI, you may go to theCMS Web site at:http://www.cms.hhs.gov/NationalProvIdentStand/03_apply.asp.Any modification to a rendering or billing providersinformation (such as a change in address orownership) requires Denti-Cal notification within 35days of the change.

Pre-enrollment InspectionPrior to enrollment in the Denti-Cal program, theapplicant or provider may be subject to a preenrollment inspection or unannounced visit.

Enrollment RequirementsPage 3-2

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Enrollment RequirementsPage 3-3

Medi-Cal Provider Group Application

(DHCS 6203, Rev. 2/08)A new Medi-Cal Provider Group Application form isrequired to report any of the following enrollmentactions:

A dentist with one or more rendering

dentists requesting to apply as a Denti-CalGroup providerA group dentist changing or requesting toadd an additional business addressA group dentist changing a Taxpayer IDnumberA group dentist changing ownership in thepractice and/or reporting a cumulativechange of 50% or more ownership orcontrolling interest

All modifications pertaining to information previously

submitted on the application must be submitted inwriting to Denti-Cal within 35 days of the date ofchange.Further instructions are included on the DHCS 6203,as well as in California Code of Regulations (CCR),Title 22, Section 51000.31.

Enrollment RequirementsPage 3-4

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Sample Medi-Cal Provider Group Application (DHCS 6203, Rev. 2/08)

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Enrollment RequirementsPage 3-5

Medi-Cal Provider Application

(DHCS 6204, Rev. 2/08)A new Medi-Cal Provider Application form is requiredto report any of the following enrollment actions:

All modifications pertaining to information previously

submitted on the application must be submitted inwriting to Denti-Cal within 35 days of the date ofchange.Further instructions are included on the DHCS 6204,as well as in California Code of Regulations (CCR),Title 22, Section 51000.30.

Enrollment RequirementsPage 3-6

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Sample Medi-Cal Provider Application (DHCS 6204, Rev. 2/08)

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Enrollment RequirementsPage 3-7

Medi-Cal Change of Location Form for

Individual Physician or Individual DentistPractices Relocating Within the SameCounty (DHCS 9096, Rev 1/11)A new Medi-Cal Change of Location form forIndividual Physician or Individual Dentist PracticesRelocating Within the Same County is available forthose who meet the following criteria:

The dental provider must meet the

definition of an individual dentist practiceas defined in W&I Code, Section14043.1(I)(1).The dental provider must be changing thelocation of his or her individual dentalpractice within the same county.The information submitted by the dentalprovider in his or her last approved Medi-Calapplication package, including their lastMedi-Cal Disclosure Statement, remainstrue, accurate and complete to the best ofthe dental providers knowledge and belief.

All modifications pertaining to information previously

submitted on the application must be submitted inwriting to Denti-Cal within 35 days of the date ofchange.Further instructions are included on the DHCS 9096.

Enrollment RequirementsPage 3-8

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Sample Medi-Cal Change of Location Form for Individual Physician or Individual Dentist PracticesRelocating Within the Same County (DHCS 9096, Rev 1/11)

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Enrollment RequirementsPage 3-9

Medi-Cal Disclosure Statement

(DHCS 6207, Rev. 2/15)A new Medi-Cal Disclosure Statement is requiredwhen either the Medi-Cal Provider Application (DHCS6204) or Medi-Cal Provider Group Application (DHCS6203) are submitted.All modifications pertaining to information previouslysubmitted on the application must be submitted inwriting to Denti-Cal within 35 days of the date ofchange.Further instructions are included on the DHCS 6207,as well as in California Code of Regulations (CCR),Title 22, Section 51000.30.

Enrollment RequirementsPage 3-10

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Sample Medi-Cal Disclosure Statement (DHCS 6207, Rev. 2/15)

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Enrollment RequirementsPage 3-11

Medi-Cal Provider Agreement

(DHCS 6208, Rev. 11/11)A new Medi-Cal Provider Agreement is required wheneither the Medi-Cal Provider Application (DHCS 6204)or Medi-Cal Provider Group Application (DHCS 6203)are submitted.All modifications pertaining to information previouslysubmitted on the application must be submitted inwriting to Denti-Cal within 35 days of the date ofchange.Further instructions are included on the DHCS 6208,as well as in California Code of Regulations (CCR),Title 22, Section 51000.30.

Enrollment RequirementsPage 3-12

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Sample Medi-Cal Provider Agreement (DHCS 6208, Rev. 11/11)

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Enrollment RequirementsPage 3-13

Medi-Cal Supplemental Changes

(DHCS 6209, Rev. 2/08)A Medi-Cal Supplemental Changes application isrequired to report any of the following actions within35 days of the date of the change:1.

Further instructions are included on the DHCS 6209,

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Sample Medi-Cal Supplemental Changes (DHCS 6209, Rev. 2/08)

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Enrollment RequirementsPage 3-15

Medi-Cal Rendering Provider

Application/Disclosure Statement/Agreement for Physician/Allied DentalProviders (DHCS 6216, Rev. 2/15)A new Medi-Cal Rendering Provider Application isrequired when adding an (unenrolled) RenderingProvider to the Denti-Cal Program.All modifications pertaining to information previouslysubmitted on the application must be submitted inwriting to Denti-Cal within 35 days of the date ofchange.Further instructions are included on the DHCS 6216,as well as in California Code of Regulations (CCR),Title 22, Section 51000.30.

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National Provider Identifier Registration

Form (DHS 6218, Rev. 2/08)Billing and rendering providers enrolled in the DentiCal program prior to 5/23/07 must register theirNPI(s) using either the following:1.2.

NPI Registration Form (DHCS 6218)

Denti-Cal NPI Collection System

Providers may request an NPI Registration Form by

calling the Denti-Cal Telephone Service Center at(800) 423-0507 or by accessing the NPI RegistrationForm (DHCS 6218) on the Denti-Cal Web site:http://www.denti-cal.ca.gov/WSINPIInfo.jsp?fname=NPIMain.The Denti-Cal NPI Collection System is found on theDenti-Cal Web site: http://www.denti-cal.ca.gov/WSI/NPIWebCollection.jsp?fname=NPIWebCollection.

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Enrollment RequirementsPage 3-21

Provisional Provider Status

The Welfare and Institutions Code (W & I) states:Section 14043.26 - New providers will be enrolled asprovisional providers. These providers shall besubject to the terms of provisional provider status fora period of 12 months from the date of enrollment.After successful completion of the 12-monthprovisional period, the providers status will bechanged to reflect regular, active status.All applications must be processed within 180 daysand, upon approval, are granted provisional providerstatus for 12 months. If the provider is not notifiedafter 180 days, provisional provider status willautomatically be invoked.Section 14043.28 - Providers who are subsequentlydenied enrollment will not be eligible to reapply for aperiod of three (3) years.Section 14123.25 - Providers will be notified ofimproper billing practices via deficiency notices.Subsequent notices to the same providers may resultin civil penalties being imposed by the Department.Section 14172.5 - The Department shall pursueliquidation of overpayment 60 days after issuance ofthe first statement of accountability or demand forrepayment, regardless of the status of the providersappeal.

Preferred Provisional Provider Status

The Welfare and Institutions (W & I) Code section14043.26(d) allows providers who meet the criteriaidentified in that section to be considered within 60days for enrollment in the Medi-Cal program aspreferred provisional providers.Based upon the authority granted to the director ofthe Department of Health Care Services (DHCS) in W& I Code section 14043.75(b), the director hasestablished the following procedures that must befollowed for a provider to request enrollment in theMedi-Cal Dental program as a preferred provisionalprovider. These procedures implement W & I Codesection 14043.26(d) as it relates to dental providersand have the full force and effect of law pursuant toW & I Code section 14043.75(b). These proceduresare effective for all application packages received onor after December 27, 2012.Enrollment RequirementsPage 3-22

If the applicant does not meet the criteria for a

preferred provisional provider, or the applicationpackage submitted fails to meet the requirements setforth, the applicant shall be notified within 60 days,and the submitted application package shall beprocessed under W & I Code section 14043.26 within180 days from the date of the notice to the applicantor provider that s/he does not qualify as a preferredprovider.If a provider has already submitted an application toDenti-Cal for enrollment and they would like torequest to be considered for a preferred provisionalprovider, they must meet all the criteria in item twobelow and submit all documentation listed in itemtwo that was not already included in applicationpackage submitted along with a Cover Letter forPreferred Provisional Provider Enrollment as directedin item three below.If the Medi-Cal Dental Program finds that a providerfalsely certified that they meet the criteria to be apreferred provisional provider, the Medi-Cal DentalProgram will recoup all payments for claims fromDenti-Cal to provider.

Procedures for Enrollment as a

Preferred Provisional ProviderAn applicant or provider requesting consideration forenrollment as a preferred provisional provider mustdo all of the following:1.

application package requesting enrollment

as a preferred provider, its attachments orin the Cover Letter for Preferred ProvisionalProvider Enrollment or its requiredstatement, will result in denial ortermination of the provisional providerstatus, and may result in further legalaction.2.

3.

4.

5.

6.

7.

Meet all of the following criteria and submit

the listed documentation at the time ofsubmission of the application package to thedepartment:Hold a current license as a dentist issued bythe Dental Board of California, which has notbeen revoked, whether stayed or not,currently suspended, on probation, orsubjected to other limitation. To meet thiscriterion, the applicant must include a copyof his/her dental license.Submit documentation showing the dentalprovider is credentialed by a health careservice plan licensed under the Knox-KeeneHealth Care Service Plan Act of 1975.Documentation may come in various formsincluding, but not limited to, a letter by theKnox-Keene licensed plan notifying theprovider that they have successfully enrolledin the Knox-Keene licensed plan, theprovider's most recent beneficiary rosterfrom the Knox-Keene licensed plan withoutPHI, or proof of payment by a Knox-Keenelicensed plan.Have never had revoked and/or suspendedprivileges through the California Medicaidprogram Medi-Cal Dental.Have no adverse entries in the HealthcareIntegrity and Protection Data Bank/NationalPractitioner Data Bank (HIPDB/NPDB). Tomeet this criterion, the applicant mustsubmit documentation from HIPDB/NPDBverifying that the database has no adverseentries regarding the applicant.Include in the application package a CoverLetter for Preferred Provisional ProviderEnrollment in which the applicant declaresunder penalty of perjury under the laws ofthe state of California that s/he meets all the

Third Quarter, 2016

criteria of a preferred provisional provider,

has no adverse entries in the HIPDB/NPDBand holds a current license as a dentistthrough the Dental Board of California,which has not been revoked, whether stayedor not, suspended, placed on probation, orsubjected to other limitation. The providershall identify the place in California wherethe statement is made and include the dateand signature of the applicant.

Enrollment RequirementsPage 3-23

Tax Identification Number

Verify Your Tax Identification Number (TIN)The Denti-Cal Program reports annually to theInternal Revenue Service (IRS) the amount paid toeach enrolled billing provider. The Business Nameand TIN must match exactly with the name and TINon file with the IRS. TINs may be either a SocialSecurity Number (SSN) or an employer identificationnumber (EIN), which are printed on the front of thecheck and on the Explanation of Benefits (EOB).Please verify that the Business Name and TIN on thenext check/EOB are correct. If the Business Name andTIN do not match, the IRS requires Denti-Cal towithhold 28% of future payments.

legible copy of the fictitious name permit

issued by the Dental Board of California.To obtain a current application form, please contactDenti-Cal toll-free at (800) 423-0507 or visit theDenti-Cal Web site: http://www.denti-cal.ca.gov/WSI/Prov.jsp?fname=ApplicationForms. Failure tosubmit the appropriate form(s) and supportingdocumentation will delay the processing of theenrollment application and it will be returned asincomplete.To obtain the Tax Identification Change Form, pleasevisit the Denti-Cal Web site: http://www.dentical.ca.gov/.

Providers do not need to notify Denti-Cal if the

Business Name and/or TIN appearing on the Denti-Calcheck/EOB are correct.

Updating Your Tax Identification Number

Updating your TIN is necessary only when:

The Business Name and/or TIN are incorrect.

A Medi-Cal Supplemental Changes DHCS6209(Rev. 2/08) form is required to makenecessary changes. Please attach a valid,legible copy of an official preprinteddocument from the IRS (Form 147-C, SS-4Confirmation Notification, 2363 or 8109C).The business type has changed (for example:sole proprietorship, corporation orpartnership). Providers are required tocomplete a new Medi-Cal Provider GroupApplication DHCS 6203 (Rev. 2/08); or aMedi-Cal Provider Application DHCS 6204(Rev. 2/08), Medi-Cal Disclosure Statement DHCS 6207 (Rev. 2/15), and Medi-CalProvider Agreement - DHCS 6208 (Rev.11/11).Provider has incorporated. Attach a valid,legible copy of the Articles of Incorporationshowing the name of the corporation and alegible copy of an official preprinteddocument from the IRS (Form 147-C, SS-4Confirmation Notification, 2363 or 8109-C).A providers corporation is doing businessunder a fictitious name. Attach a valid,

Enrollment RequirementsPage 3-24

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Tax Identification Change Information

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Enrollment RequirementsPage 3-25

No Claim Activity for 12 Months

In order to remain actively enrolled in the Denti-CalProgram, providers must comply with all enrollmentrequirements.Denti-Cal Program providers will automatically beinactivated from the Denti-Cal Program if any of thefollowing occurs:

Dental license is expired, revoked,

inactivated, denied renewal, or suspendedby the Dental Board of California;Mail is returned by the post office markedUndeliverable due to incorrect address;Twelve months with no claim activity in theDenti-Cal Program.

Upon inactivation, providers will be required to reapply to the Denti-Cal Program. To receive the mostcurrent enrollment application and information,please request an application by calling theTelephone Service Center at (800) 423-0507 or goingto the Denti-Cal Web site: http://www.dentical.ca.gov/WSI/Prov.jsp?fname=ApplicationForms.As a participating Denti-Cal provider, it is importantto keep Denti-Cal records up to date by promptlyreporting any changes to previously submittedinformation, e.g. name and address changes, theaddition of associates or the sale of a practice.Providers must notify Denti-Cal in writing to changeor correct your provider name/address information.Denti-Cal must receive a signed authorization within35 days from the date the change occurred in orderto make any changes to provider information records.Providers who have had no claim activity (submittingno claims or requesting reimbursement) in a 12month period shall be deactivated per Welfare andInstitutions Code Section 14043.62 which reads asfollows:The department shall deactivate, immediately andwithout prior notice, the provider numbers usedby a provider to obtain reimbursement from theMedi-Cal program when warrants or documentsmailed to a providers mailing address or its pay toaddress, if any, or its service or business address,are returned by the United States Postal Service asnot deliverable or when a provider has notEnrollment RequirementsPage 3-26

submitted a claim for reimbursement from the

Medi-Cal program for one year. Prior to taking thisaction the department shall use due diligence inattempting to contact the provider at its lastknown telephone number and ascertain if thereturn by the United States Postal Service is bymistake or shall use due diligence in attempting tocontact the provider by telephone or in writing toascertain whether the provider wishes to continueto participate in the Medi-Cal program. Ifdeactivation pursuant to this section occurs, theprovider shall meet the requirements forreapplication as specified in this article or theregulations adopted thereunder.To remain active in the Denti-Cal Program, completethe form on the previous page and mail it to:Denti-CalAttn: Enrollment DepartmentPO Box 15609Sacramento, CA 95852-0609If the form is not received by Denti-Cal prior to theend of the 12-month period, the provider number willbe deactivated. If a provider number is deactivated,the provider must reapply for enrollment in theDenti-Cal Program. To request an enrollment packagecontact Denti-Cal toll free at (800) 423-0507.The No Claim Activity form is available on the DentiCal Web site: http://www.denti-cal.ca.gov/.

Voluntary Termination ofProvider ParticipationA provider may terminate his or her participation inthe Denti-Cal Program at any time. Writtennotification of voluntary termination must include theprovider's original signature, in blue or black ink(rubber stamps are not acceptable), and a currentcopy of the providers drivers license must beattached for signature verification. Send to:Denti-CalAttn: Provider ServicesPO Box 15609Sacramento, CA 95852-0609

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No Claim Activity for 12 Months Form

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Enrollment RequirementsPage 3-27

Enrollment of Billing Intermediaries

Denti-Cal providers who use a billing intermediary forclaims preparation and submission must notify DentiCal of their billing arrangements. A billingintermediary may include any entity, such as apartnership, corporation, sole proprietorship orindividual, contracted with a provider to bill theDenti-Cal program on his or her behalf. A provider'ssalaried employees are not considered billingintermediaries.

The Department instructs Denti-Cal to

withdraw the registration of a provider'sbilling intermediary.

A provider who wishes to use a billing service must

complete a Medi-Cal Dental Provider and BillingIntermediary Application/Agreement and send it toDenti-Cal. A provider should use this form to notifyDenti-Cal of the initiation, renewal or termination of abilling intermediary contract. Billing servicessubmitting claims to Denti-Cal must register with theDenti-Cal Program by completing a BillingIntermediary Registration Form. Upon registration,Denti-Cal will assign a registration number which thebilling service must include on all claims submitted.To obtain either a Medi-Cal Dental Provider andBilling Intermediary Application/Agreement or aBilling Intermediary Registration Form, providersshould call Denti-Cal toll-free at (800) 423-0507 orwrite to:Denti-CalAttn: Provider ServicesPO Box 15609Sacramento, CA 95852-0609When a provider notifies Denti-Cal of billing servicearrangements, Denti-Cal will acknowledge thenotification within 10 days. Denti-Cal will also notify aprovider when one of the following occurs:

A billing intermediary notifies Denti-Cal that

it has contracted with a provider;A billing intermediary notifies Denti-Cal thatit has terminated its contract with aprovider;A billing intermediary that submits claims fora provider notifies Denti-Cal that it iswithdrawing its registration as a Denti-Calbilling intermediary;

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How to Complete the Medi-Cal Dental

Provider and Billing IntermediaryApplication/AgreementProviders must use this form to notify Denti-Cal whenthey initiate, renew or terminate a contract with abilling intermediary. The form contains the following:1.

2.3.4.5.

6.

7.

8.

Type of Request: Use an X to indicate the

request type: Initial Registration Add Provider(s) Terminate Registration Delete Provider(s)Provider Name (full legal): Enter the providersname.Doing Business Name (if applicable): Enter theproviders Doing Business As name.National Provider Identifier (NPI): Enter theproviders NPI number.Provider Service Address (number, street): Enterthe providers street address, city, state, and zipcode in these fields.Contract Begin Date (mm/dd/yyyy): Beginningdate of the contract between the provider andthe billing intermediary.Contract End Date (mm/dd/yyyy): Date thecontract between the provider and billingintermediary will end (unless it is renewed).Contact Person Title/Position: Enter the name,title, e-mail address, telephone number (witharea code), and drivers license or state-issuedidentification and state of issuance in thesefields.

billing service has not yet registered with DentiCal).

11. Business Address (number, street): Completethe fields for the billing services address,including street address, city, state and zip code.12. Owner contact number: Enter the ownerstelephone number (with area code) and driverslicense or state-issued identification and state ofissuance in these fields.13. PROVIDER SIGNATURE INFORMATION/BILLINGSERVICE SIGNATURE INFORMATION: Both theprovider and the billing service need to sign bothpage one and page two of the form.When submitting the form, make sure to include thefollowing:

If the billers information is different than the

provider of services, then complete the followingsections:9.

Owner Name (full legal name with 5% or more

ownership/interest): Enter the owners nameand telephone number.10. Biller Service Registration Number: Theregistration number assigned to the billingintermediary, if applicable. (NOTE: The assignedregistration number may not yet be available to aprovider who is notifying Denti-Cal of a newcontract with a billing service, especially if the

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Enrollment RequirementsPage 3-31

Electronic Data Interchange (EDI)

To submit documents and receive correspondingreports electronically, dentists who have enrolled andare certified to participate in the Denti-Cal Programmust apply and be approved by Denti-Cal toparticipate in the EDI program. The Medi-Cal DentalTelecommunications Provider and BillerApplication/Agreement (for electronic claimsubmission), hereinafter Trading PartnerAgreement, must be signed and submitted alongwith the Provider Service Office Electronic DataInterchange Option Selection Form. Failure or refusalto sign this Agreement may be grounds for immediatesuspension from participation in the electronic claimssubmission program pursuant to Title 22, CaliforniaCode of Regulations (CCR) 51502.1(j). ThisAgreement is also required for EDI clearinghousesand billing intermediaries billing electronically onbehalf of Denti-Cal providers. Providers can alsoauthorize Denti-Cal to provide remittance dataelectronically by completing the ElectronicRemittance Advice (ERA) Enrollment Form.When a provider is enrolled in the Denti-Cal EDIprogram, Denti-Cal sends the provider a letterconfirming the providers EDI enrollment.Confirmation is also sent by e-mail if a valid e-mailaddress is available.

clearinghouse has been certified through Denti-Cal,

prior to submitting claims.

Ineligibility for EDI

A Denti-Cal provider is not eligible for EDI if, withinthe past three years, criminal charges were filedagainst the provider for fraudulently billing the MediCal program, or if the provider has been suspendedfrom the Medi-Cal program, or has been required topay recovery to Medi-Cal for overpayments in excessof 10 percent of the providers total annual Medi-Calincome.If a Denti-Cal provider has been placed on PriorAuthorization (PA) and/or Special Claims Review(SCR), submitting electronically is still possible.Providers must flag the radiograph or the attachmentindicator to Y (Yes) for procedures on PA and/orSCR to avoid the claim from being denied.A copy of the HIPAA Transaction Standard CompanionGuide (Denti-Cal EDI Companion Guide), as well asthe Trading Partner Agreement, can be obtained byphoning Telephone Service Center toll-free at (800)423-0507 or (916) 853-7373 and asking for EDISupport. Requests may also be sent by e-mail todenti-caledi@delta.org.

HIPAA-Compliant Electronic Format Only

Denti-Cal accepts only the HIPAA-compliantelectronic format for claims (ASC X12N 837) and claimstatus (ASC X12N 276) from certified trading partners.A provider submitting claims electronically is requiredto undergo certification for the HIPAA-compliantformat. However, if a provider is submitting claimselectronically through its contracted clearinghouse,only the clearinghouse must be certified. In this case,a provider must ensure that its contracting

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Sample Electronic Remittance Advice (ERA) Enrollment Form - Page 1

Enrollment RequirementsPage 3-36

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Sample Electronic Remittance Advice (ERA) Enrollment Form - Page 2

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Enrollment RequirementsPage 3-37

Electronic Claims Submission and

Payment ServicesSubmitting claims electronically reduces processingtime for claims, makes billing and tracking documentseasier, and helps maximize computer capabilities.EDI-enrolled providers can also receive the Notice ofAuthorization (NOA) and Resubmission TurnaroundDocument (RTD) forms electronically along with otherEDI reports.For an EDI Enrollment Packet, please contact ProviderServices toll-free at (800) 423-0507. For an EDI HowTo Guide or other information on submitting DentiCal claims and Treatment Authorization Requests(TARs) electronically, please call EDI Support at (916)853-7373. Requests may also be sent by e-mail todenti-caledi@delta.org. Providers may also access EDIenrollment forms and Guides from the Denti-Cal Website: http://www.denti-cal.ca.gov/WSI/Prov.jsp?fname=EDI.A dental office wishing to use EDI must have acomputer system that includes an internetconnection and a software program that will allowthe transmission of claims. If the office already has acomputer, check with the practice managementsystem vendor to determine if the software willenable submitting of claims electronically to DentiCal. The software vendor can also assist indetermining the best computer hardware andsoftware options for electronic claims processingneeds.EDI enrollment allows providers to send TARs, claimsand NOAs for payment, over the telephone line orthrough File Transfer Protocol (FTP) directly from theoffice to Denti-Cal, or through a billing intermediaryor clearinghouse. EDI gives providers the option ofreceiving claims-related information electronicallyfrom Denti-Cal, such as reports, Explanation ofBenefits (EOBs) and Electronic Remittance Advice(ERA) data for performing automated accountsreceivable reconciliation.EDI Providers who receive the 835 ElectronicRemittance Advice (ERA) and/or Supplemental EOBfile in Detail format may opt to discontinue receivingpaper EOBs. In order to stop receiving paper EOBs,providers enrolled to submit electronically mustEnrollment RequirementsPage 3-38

complete and submit the Provider Service Office

Electronic Data Interchange Option Selection formreflecting that option. The decision to not receive apaper EOB will not affect the mailing of a provider'schecks.The EDI system format also allows the electronicsubmission of comments which may be pertinent tothe treatment requested or provided. Denti-Calprovides identification labels and specially markedenvelopes for mailing additional information (such asradiographs, periodontal charting, or otherdocumentation) which may be required to processelectronically submitted treatment forms.Use red-bordered EDI envelopes and EDI labels onlywhen Denti-Cal requests them through the XRay/Attachment Request report (CP-O-971-P).Use green-bordered envelopes when submittingclaims, NOAs and RTDs (conventional paper forms) orthose made available electronically that are printedonto paper and mailed in for processing as well asClaim Inquiry Forms (CIFs). No EDI labels on EDI RTDsor NOAs, please.

What Can Be Sent Electronically to Denti-Cal

The following items can be transmitted electronically:

Claims,TARs,NOAs for payment when treatment iscompleted (if the system or clearinghousecan accept them; only selected software andclearinghouses include the EDI NOA feature).Radiographs,Periodontal evaluation charts,Justification of Need for Prosthesis Forms(DC054), andNarrative documentation (surgical reports,etc.)

The following items cannot be transmitted

electronically and must be mailed to Denti-Cal:

Completed RTDs (even those provided

electronically that are printed on paper),NOAs (if the system cannot submit themelectronically),requests for reevaluation,Third Quarter, 2016

CIFs, RTDs, or NOAS issued for paper or EDI

Within 24 to 48 hours after sending documents

electronically, Denti-Cal provides anacknowledgement report to confirm receipt of claimsand TARs (CP-O-973-P: Daily EDI Documents ReceivedToday). Another report (CP-O-971-P: XRay/Attachment Request) is issued the same day theacknowledgement report is issued if documentationis needed.It is important to review these reports to verifysubmitted forms and documentation are beingreceived by Denti-Cal. If these reports are not beingreceived, check with your vendor, clearinghouse, orEDI Support.

Sending Radiographs and Attachments

Providers should maintain a supply of EDI labels andenvelopes (small and large X-ray envelopes, andmailing envelopes) which are printed in red ink.When entering the document into the practicemanagement system, determine whetherradiographs or documentation are needed. If soprepare EDI labels and envelopes:

Insert the radiographs into an EDI X-ray

envelope.Affix a blank label onto the outside of theenvelope.Staple any necessary documentation, such asa Justification of Need for Prosthesis form(DC054) or periodontal chart, onto theoutside of the X-ray envelope.Write the patient's name under BIC to helpyou identify the patient.

Upon receipt of the X-ray/Attachment Request

report, write the 11-digit Base DCN next to Denti-CalDCN and mail it to Denti-Cal in the large mailingenvelope marked with the special EDI post office box.Attachments, such as claims information, transmittedelectronically to Denti-Cal are delivered to Denti-Cal'scomputer system for processing. Denti-Cal providersmay use EDI to submit treatment forms and receivereports and other electronic data 24 hours per dayThird Quarter, 2016

Monday through Saturday, and from 12 noon to 12

a.m. on Sunday (excluding holidays). Electronicdocuments received at Denti-Cal by 6:00 p.m.Monday through Saturday are entered into EDIprocessing the same evening. Staff are also availableto answer EDI-related questions and assist with anyproblems an office may be experiencing withelectronic claims transmission Monday throughFriday during normal work hours.

Telephone Service Center toll-free, (800)

423-0507EDI Support, (916) 853-7373e-mail: denti-caledi@delta.org

Digitized Imaging Vendor and

Document SpecificationsDigitized radiographs, photographs, periodontalevaluation charts, scanned State-approvedJustification of Need for Prosthesis forms (DC054),and other narrative reports may be submitted inconjunction with EDI claims and TARs through NEA,NIS or Tesia Clearinghouse, LLC Web sites.NEA Users: Digitized radiographs and attachmentsmust be transmitted to NEA before submitting an EDIdocument. NEAs reference number must be enteredon the EDI claim or TAR in the following format:NEA# followed by the reference number, with nospaces - Example: NEA#9999999. It is important touse this format and sequence.Some dental practice management and electronicclaims clearinghouse software have an interface withNEA that automatically enters the reference numberinto the notes of the claim. For additionalEnrollment RequirementsPage 3-39

information, providers can visit

http://www.nea-fast.com or call (800) 782-5150NIS Users: The EDI document should be created.Before transmitting a document electronically, thedigitized radiographs and attachments should beattached. The Document Center should be used toscan images of Denti-Cals Justification of Need forProsthesis Form (DC054), perio charts, photos, etc.The date images were created should be entered inthe notes for each attachment. For additionalinformation, providers can visitwww.nationalinfo.com or call (800) 734-5561.Tesia Clearinghouse, LLC Users: Create the claim orTAR. Before transmitting a document electronically,the digitized images should be created and attached.Each attachment must include the date the imageswere created. For additional information, providerscan visit www.tesia.com or call (800) 724-7240.Please note:

Images should not be transmitted for EDI

claims or TARs that are already waiting forradiographs and/or attachments to bemailed.Digitized images of Claim Inquiry Forms(CIFs), Resubmission Turnaround Documents(RTDs) and Notices of Authorization (NOAs)or digitized images related to paperdocuments cannot be processed.When submitting CIFs by mail, providershave the option of not submitting hardcopies of radiographs and otherdocumentation related to a CIF if theprovider indicates digitized image referencenumbers in the form's remarks box. If aprovider chooses not to include digitizedimage reference numbers on a CIF, theprovider must send in hard copies.Denti-Cal is unable to respond to inquiriessubmitted through digitized imagingvendors Web sites. Instead, CIFs should bemailed to Denti-Cal.Radiographs are not required for dentureson edentulous patients. Submit Justificationof Need for Prosthesis forms (DC054) only.

Enrollment RequirementsPage 3-40

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Medi-Cal Dental Patient Referral Service

Denti-Cal providers can take advantage of a freereferral service for accepting Denti-Cal patients. Thisreferral service can be an excellent resource forenrolled Denti-Cal providers to build, maintain orincrease their patient base while making available thehighest level of dental service for the Californiasmedically needy.If you are a provider interested in this service, orneed to update the information currently on file,please fill out the Medi-Cal Dental Patient ReferralService Form. Return the completed form in one ofthe following ways:Mail:

California Medi-Cal Dental Program

Attn: Enrollment DepartmentPO Box 15609Sacramento, CA 95852-0609

E-mail:

Denti-CalEnrollmentDept@delta.orgSend a scanned image of the completedform to the e-mail address above.

If you have any questions about the form or the

Third Quarter, 2016

Sample Medi-Cal Dental Patient Referral Service Form - Page 1

Enrollment RequirementsPage 3-42

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Sample Medi-Cal Dental Patient Referral Service Form - Page 2

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Enrollment RequirementsPage 3-43

Electronic Funds Transfer of Payment

Denti-Cal offers electronic funds transfer of Denti-Calpayments to a designated checking or savingsaccount. To begin participating in electronic fundstransfer, you must complete and sign an ElectronicFunds Transfer Enrollment Form. Forms may berequested by calling Provider Services at (800) 4230507, or by writing to Denti-Cal at this address:Denti-CalAttn: Provider Enrollment DepartmentPO Box 15609Sacramento, CA 95852-0609Instructions for completing the Electronic FundsTransfer Enrollment Form are contained on the backof the form. Mail the completed form to Denti-Cal atthe address shown above. Please be sure to sign anddate the form. To be accepted for processing, theElectronic Funds Transfer Enrollment Form mustcontain the provider's original signature, in blue orblack ink (rubber stamps are not acceptable), and apreprinted, voided check must be attached.Upon receipt of the Electronic Funds TransferEnrollment Form, Denti-Cal will ensure thedesignated bank participates in electronic fundstransfer. To verify account information, Denti-Cal willsend a test deposit to the bank; there will be azero deposit to the account for that payment date.The test cycle usually takes three to four weeks tocomplete. During the test cycle period, the providerwill continue to receive Denti-Cal payment checksthrough the mail.Each time Denti-Cal deposits a payment directly to anaccount, a statement confirming the amount of thedeposit will appear on the Explanation of Benefits.Contact Denti-Cal to change or discontinue electronicfunds transfer of Denti-Cal checks. To change banksor close an account, send Denti-Cal a writtenauthorization to discontinue electronic funds transferof Denti-Cal checks.

Treating BeneficiariesBeneficiary IdentificationMedi-Cal Benefits Identification CardDenti-Cal does not determine the eligibility ofbeneficiaries. Eligibility for the Denti-Cal Program isdetermined by a County Social Services office andreported to the State of California. The State, in turn,issues aMedi-Cal Benefits Identification Card (BIC) tobeneficiaries who are eligible for Medi-Cal benefits.The BIC serves as a permanent identification for aMedi-Cal beneficiary; however, possession of thecard does not guarantee eligibility for Medi-Calbenefits, since the card can be retained by thebeneficiary whether or not the beneficiary is eligiblefor the current month.

Figure 4-1, CCS Number (Numeric, 10 digit)

For more information, see the following Web site:

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part1/eligreccrd_z01.doc.BIC cards are 3 inches long and 2 inches widewith a white background. The lettering is blue on thefront and black on the back. Printed on the front ofthe card is a

Figure 4-2, Pseudo SSN (Alphanumeric, 10

characters)

14-character alphanumeric identification (ID)

number. The ID number is comprised of a ninecharacter alphanumeric, a check digit and a fourdigit Julian date matching the issue date of the BIC.Only California Childrens Services (CCS) beneficiarieswill have a BIC with a 10-character ID. All otherMedi-Cal beneficiaries have received a BIC with a 14character ID. If beneficiaries have not received the14-character BIC ID, refer them to their local countyoffice.

Figure 4-3, 14 Digit BIC Number (Alphanumeric, 14

characters)

Figure 4-4, BIC (Back)

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Treating BeneficiariesPage 4-1

Special Programs Identification Cards

Some Medi-Cal beneficiaries may be enrolled inspecial programs, such as prepaid health plans andpilot projects. A beneficiary enrolled in one of theseplans who is eligible for dental services should havean identification card from the plan as well aspossess a Medi-Cal Benefits Identification Card. A listof current special project and prepaid health plancodes can be found in Section 9: Special Programsof this Handbook.

Medi-Cal Identification Card for

Presumptive Eligibility (MC 263 PREMEDCARD(4/96)) for Aid Code 7GIn order to receive payment for services provided topregnant beneficiaries in Aid Code 7G, providersmust submit a copy of the beneficiary's temporaryPresumptive Eligibility (PE) card with their claim (seebelow for a sample of the card). The PE card is arequired form of identification. Substitutions shouldnot be accepted. This card is validated by thebeneficiary's physician attending to the beneficiaryspregnancy and is valid until the Medi-Cal eligibility isdetermined or the PE period ends. This date isidentified on the temporary PE card as the FirstGood Thru date. Some beneficiaries may be eligiblefor extended PE coverage. In such cases, thetemporary PE card will have a Second Good Thrudate, and sometimes additional Good Thru dates.Once approved for Medi-Cal, the beneficiary willreceive a plastic BIC.Providers will only be paid for claims with dates ofservice that are between the effective date (the datethe beneficiary signs the card) and the latest GoodThru date. The date of service must be within thevalidated time frame and, if not, providers shouldinstruct the beneficiary to see a prenatal careprovider, call an Eligibility Worker and/or acommunity advocate.

Figure 4-5, Medi-Cal Identification Card

Presumptive Eligibility

Immediate Need Cards

In certain situations, county welfare departmentswill issue Medi-Cal beneficiaries temporary BICs toImmediate Need and Minor Consent Programrecipients (see below for a sample of the card).The ID number (ID NO.) is the 14-character BIC ID:this is used to access the Medi-Cal EligibilityVerification System. Prior to rendering services,providers must verify the beneficiarys eligibility andthat the beneficiary with the BIC is the individual towhom the card was issued.Temporary BICs issued to Immediate Need recipientsare valid for identification purposes for 30 days, asindicated on the ISSUE DATE: and GOOD THRU:lines. The valid dates may occur in two consecutivemonths and are only used for identificationpurposes. Providers must verify the beneficiaryseligibility through a Point of Service (POS) networkbefore rendering services.The temporary BICs received by Minor ConsentProgram recipients are valid for identification forone year. However, the recipient is only eligible forthe requested month. The Issue Date: and GoodThru: dates are for identification purposes only:providers must still verify the beneficiarys eligibilitythrough a POS network before rendering services.

Figure 4-6, Immediate Need Card

Treating BeneficiariesPage 4-2

Third Quarter, 2016

Verifying Beneficiary Identification

In certain instances, no identification verification isrequired, for example:When the beneficiary is 17 years of age oryounger;When the beneficiary is receivingemergency services;When the beneficiary is a resident in a longterm care facility.

If the beneficiary is unknown to the provider, the

provider is required to make a good-faith effort toverify the beneficiary's identification by matchingthe name and signature on the Medi-Cal issued ID tothat on a valid photo identification, such as:

A California drivers license;

An identification card issued by theDepartment of Motor Vehicles;Any other document which appears tovalidate and establish identity.

The provider must retain a copy of this identification

in the beneficiary's records. If there is a conflict inthe beneficiary's Denti-Cal billing history where aprovider bills or submits for authorization for aprocedure that was previously performed byanother provider, Denti-Cal will request that thecurrent provider submit a copy of the beneficiary'sidentification to verify that the services are beingprovided to the appropriate beneficiary. If thissituation occurs and the current provider cannotprovide appropriate beneficiary identification,payment or authorization for treatment will bedenied.For additional information, please refer to Welfare &Institutions (W & I) Code 14017, 14017.5, 14018, and14018.2(c).

Denti-Cal Beneficiary Eligibility

A Medi-Cal beneficiary is eligible for dental servicesprovided under the Denti-Cal Program. However,limitations or restrictions of dental services mayapply in certain situations to the followingindividuals:

Those enrolled in a prepaid health plan

which provides dental services;

Third Quarter, 2016

Those enrolled in another pilot program

which provides dental services;Those who are assigned special aid codes;Those with minor consent restricted servicecards.

According to state law, when a provider elects to

verify Medi-Cal eligibility using a BIC, a paperidentification card or a photocopy of a paper cardand has obtained proof of eligibility, he or she hasagreed to accept the beneficiary as a Medi-Calbeneficiary and to be bound by the rules andregulations of the Denti-Cal program.Providers must verify eligibility every month for eachrecipient who presents a plastic BenefitsIdentification Card (BIC) or paper Immediate Need orMinor Consent card. Eligibility verified at the first ofthe month is valid for the entire month of service. APoint of Service (POS) printout or Internet eligibilityresponse may be kept as evidence of proof ofeligibility for the month.Eligibility may be verified only for the current monthand up to the previous 12 months, never for futuremonths.A person is considered a child until the last day ofthe month in which his/her 18th birthday occurs.After that particular month, he/she is considered anadult. However, a treatment plan authorized for achild is effective until completion if there is bothcontinuing eligibility and dental necessity, regardlessof change in age status.Beneficiaries who cannot sign their name and cannotmake a mark (X) in lieu of a signature because of aphysical or mental handicap will be exempt from thisrequirement. Beneficiaries who can make a mark (X)in lieu of a signature will not be exempted from thisrequirement and will be required to make their markon the Medi-Cal identification card. In addition, thesignature requirement does not apply when abeneficiary is receiving emergency services, is 17years of age or younger, or is a beneficiary residingin a long-term care facility.If Medi-Cal eligibility is verified, the provider may nottreat the beneficiary as a private-pay beneficiary toavoid billing the beneficiary's insurance, obtainingprior authorization (when necessary) or complyingTreating BeneficiariesPage 4-3

with any other program requirement. In addition,

upon obtaining eligibility verification, the providercannot bill the beneficiary for all or part of thecharge of a Medi-Cal covered service except tocollect the Medi-Cal copayment or SOC. Providerscannot bill beneficiaries for private insurance costsharing amounts such as deductibles, co-insuranceor copayments.Once eligibility verification has been established, aprovider can decline to treat a beneficiary onlyunder the following circumstances:

The beneficiary has refused to pay or

obligate to pay the required SOC.The beneficiary has limited Medi-Calbenefits and the requested service(s) is notcovered by the Denti-Cal program.The beneficiary is required to receive therequested service(s) through a designatedhealth plan. This includes cases in which thebeneficiary is enrolled in a Medi-Calmanaged care plan or has private insurancethrough a health maintenance organizationor exclusive provider network and theprovider is not a member provider of thathealth plan.The provider is unable to provide theparticular service(s) that the beneficiaryrequires.The beneficiary is not eligible for Denti-Calservices.The beneficiary is unable to presentcorroborating identification with the BIC toverify that he or she is the individual towhom the BIC was issued.

POS device, or through the Automated Eligibility

Verification System (AEVS).

InternetThe Medi-Cal Web site on the Internet athttps://www.medi-cal.ca.gov/Eligibility/Login.aspallows providers to verify beneficiary eligibility andclear Share of Cost liability. An EVC number on theInternet eligibility response verifies that an inquirywas received and eligibility information wastransmitted. This response should be printed andkept in the recipients file.Providers who check eligibility via AEVS over thephone do not automatically have access to checkeligibility through Medi-Cal's web site. Providers whowish to use the Medi-Cal POS or Medi-Cal web siteapplications are required to have a Medi-Cal Point ofService (POS) Network/Internet Agreement on filewith Denti-Cal.Questions regarding this form or the Medi-Cal website should be directed to EDS POS/ Internet HelpDesk at (800) 427-1295.

A provider who declines to accept a Medi-Cal

beneficiary must do so before accessing eligibilityinformation except in the above circumstances. Ifthe provider is unwilling to accept an individual as aMedi-Cal beneficiary, the provider has no authorityto access the individual's confidential eligibilityinformation.

Verifying Beneficiary Eligibility

The Point of Service (POS) network is set up to verifyeligibility and perform Share of Cost. The POSnetwork may be accessed through the Internet, aTreating BeneficiariesPage 4-4

Third Quarter, 2016

POS DeviceAn EVC number on a printout from the POS deviceverifies that an inquiry was received and eligibilityinformation was transmitted. This printout should bekept in a recipients file. The POS Device User Guidecontains information about how to use a POS device.This guide can be accessed via the Medi-Cal Web siteat:http://files.medi-cal.ca.gov/pubsdoco/pos_home.aspNote: Information about obtaining a POS device isavailable from the POS/Internet Help Desk at (800)427-1295.

Automated Eligibility Verification System (AEVS)

An Eligibility Verification Confirmation (EVC) numberverifies that an inquiry was received and eligibilityinformation was transmitted. (Refer tohttp://files.medi-cal.ca.gov/pubsdoco/AEVS_home.asp for information about usingtelephone AEVS.)The table below show the alphabetic code listingscodes for entering alphabetic data:LetterABcDEFGHIJKLM

2 Digit Code*21*22*23*31*32*33*41*42*43*51*52*53*61

LetterN0pQRsTuvwxyz

2 Digit Code*62*63*71*11*72*73*81*82*83*91*92*93*12

Share of Cost (SOC)

If the Medi-Cal eligibility verification systemindicates a beneficiary has a Share of Cost (SOC), theSOC must be met before a beneficiary is eligible forMedi-Cal benefits. Refer to the applicabletransaction manual for directions on applying SOC.

Third Quarter, 2016

SOC was developed by the Department to ensure an

individual or family meets a predetermined financialobligation for medical and dental services beforereceiving Medi-Cal benefits. Prior authorizationrequirements are not waived for SOC beneficiaries.The SOC obligation is incurred each month and,consequently, the amount of obligation may varyfrom month to month. The dollar amount to beapplied to any health care cost incurred during thatmonth is computed in order to meet the SOC. Healthcare costs could be dental, medical, pharmaceutical,hospital, etc. Beneficiaries may use non-Medi-Calcovered services in meeting the monthly SOCobligation.Providers can determine a beneficiarys SOC whenverifying the beneficiarys eligibility through AEVS orby referring to the beneficiarys SOC Case Summaryletter. AEVS will report if a beneficiary has an unmetSOC before providing an EVC. Providers may collectpayment on the date that services are rendered, orthey may allow a beneficiary to pay for the servicesat a later date or through an installmentarrangement. SOC obligations are between thebeneficiary and the provider and they should be inwriting and signed by both parties.The Medi-Cal SOC obligation can apply to anindividual or family as a whole. Family members whoare not eligible for Medi-Cal may be included in thebeneficiary's SOC. The health care costs for theseineligible family members can be used to meet theSOC obligation for family members who are eligible.Ineligible family members who are able to do thisare identified by an IE or 00 aid code on thebeneficiarys SOC letter.Natural or adoptive parents (coded as ResponsibleRelative (RR) on their childs SOC form) may chooseto apply their medical expenses towards their ownSOC or towards their childs SOC. In this instance,parents expenses can be listed fully towards theirown SOC or applied partially towards their SOC andany of their childrens SOC. However, the totalamount reported for a single medical expensecannot be more than the original bill.An example of this situation would be a family thatconsists of a stepfather, his wife and his wifesseparate child. The wife and her husband are listedTreating BeneficiariesPage 4-5

as eligible recipients on the same SOC letter with a

$100 SOC. The wifes separate child is listed on adifferent SOC letter with a $125 SOC. The wife is alsolisted on her childs SOC letter with an RR code inthe aid code field.The wife has expenses that total $75 and that havenot been billed to Medi- Cal. She may do one of thefollowing:1.2.3.

Apply the entire $75 to her own $100 SOC.

Apply the entire $75 to her own childs $125SOC.Apply any amount less than $75 to her SOC andthe balance of the $75 to her childs SOC. Thetotal amount reported cannot exceed theoriginal $75.

Providers should submit a SOC clearance transaction

immediately upon receiving payment from thebeneficiary. The SOC clearance transaction can beperformed by entering the amount through AEVS.Once this amount has been entered, eligibility canbe established for that month for the familymembers eligible for Medi-Cal. If the beneficiarysSOC obligation has been met, providers are entitledto bill Denti-Cal for those services that have beenpartially paid for by the beneficiary and all otherservices not paid for by the beneficiary. However,total payments from the beneficiary and Denti-Calwill not exceed the Schedule of MaximumAllowances (SMA).

Interactive Voice Response (IVR) System

The Denti-Cal Interactive Voice Response (IVR)System is a touch-tone only system providinggeneral program information. General programinformation is available 24 hours a day, seven days aweek on the IVR system. To by-pass the entireresponse, press the required key.Patient history, claim/TAR status and financialinformation can be accessed using the IVR system,seven days a week, 2:00 a.m. to 12:00 midnight, withlittle or no wait time.

between 8:00 a.m. and 9:30 a.m., and 12:00 noon

and 1:00 p.m.).To access the IVR, enter the star key (*) followed bythe providers NPI.The IVR allows providers to check history and billingcriteria.Patient history information can be obtained byentering the NPI followed by the pound (#) key andentering the current Denti-Cal service office number.Then press 1 from the main menu and enter theprovider identification (ID) number. If the providerID number starts with B, press the star (*) key,then the number 2, and the number 2 again,followed by the five numbers of your assignedprovider number. If the provider number starts withG press the star (*) key, then the number 4,followed by the number 1, followed by the fivenumbers of your assigned provider number. Beginentering patient information by pressing 1 again,then follow the prompts. This option in the IVR giveshistory on radiographs, prophylaxes, dentures, andmany other procedures.Providers may verify the available balance of abeneficiarys dental cap. For information regardingbeneficiary cap status, press 1, then press 3, andfollow the prompts. Providers are reminded thatbeneficiary cap information is contingent uponpatient eligibility and does not include anydocuments currently in process.Providers may request by FAX: the Schedule ofMaximum Allowances (SMA) and the clinicalscreening dentist application. In addition to detailsregarding basic and advanced seminars, providersmay now get information on orthodontic seminarsand workshops.Note: To check beneficiary eligibility, continue to useAEVS: (800) 456-2387.

Note: Beneficiary aid code status is only accessible

by speaking with a Customer Service Representativeby calling (800) 322-6384, Monday through Friday,between 8:00 a.m. and 5:00 p.m. (the best time isTreating BeneficiariesPage 4-6

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Third Quarter, 2016

Treating BeneficiariesPage 4-7

Beneficiary CoverageElimination of Optional Adult Dental ServicesEffective July 1, 2009, Assembly Bill X3 5 (Evans,Chapter 20, Statutes of 2009-10) added Section14131.10 to the Welfare and Institutions Code, whicheliminated specific optional benefits from the MediCal program, including most adult dental services.Dental services for adults ages 21 and older will nolonger be payable under the Denti-Cal program withthe following exceptions:

Federally Required Adult Dental Services

(FRADS) - Federal law requires the provisionof services by a dentist which a physiciancould reasonably provide (please refer toTable 1 below for a list of allowableprocedure codes).Dental services for pregnant beneficiaries fortreatment of conditions that mightcomplicate the pregnancy including 60 dayspost partum.Dental services that are necessary as either acondition precedent to other medicaltreatment or in order to undergo a medicalsurgery.Dental services for beneficiaries who residein a licensed Skilled Nursing Facility (SNF) orlicensed Intermediate Care Facility (ICF).Refer to Section 2: Program Overview formore information.

Dental Treatment Precedent to a Covered

Medical ProcedureDental services that are necessary as either acondition precedent to other medical treatment or inorder to undergo a medical surgery.Beneficiaries may receive dental services that arenecessary in order to undergo a covered medicalservice. A precedent dental service is one that ismedically necessary in order for a medical procedureto subsequently be performed. Virtually all precedentdental services are for the improvement orelimination of transient bacteremia (the presence ofbacteria in the bloodstream of the patient). Oneexample is when a patient is scheduled for a hearttransplant, and oral infections need to be eliminatedprior to the surgery. For many of these cases, theextraction of infected teeth is the most prevalent andThird Quarter, 2016

effective treatment. Tooth extractions are covered by

the Denti-Cal Program under FRADS (see Table 1),and do not require a Treatment AuthorizationRequest (TAR).When providers request treatment other thanextractions or other FRADS procedures that do notrequire prior authorization, they must submit a TARfor those services. Necessary diagnosticradiographs/photographs and exams, however, maybe done without prior authorization when they areincluded on the same TAR as the treatmentrequested. Providers should submit the followingdocumentation with their TAR; all requiredradiographs/photographs for the specificprocedure(s) requested, as well as all requiredwritten documentation and/or forms. In addition,providers must submit a letter from the patient'sphysician that details the specific medicalprocedure(s) that are to be performed. Thisstatement must be on the physician's or implantcenter's professional letterhead and must be signedand dated by the physician.TARs for dental treatment precedent to a medicalprocedure will be subject to special handling. Pleasecall the Telephone Service Center at (800) 423-0507for special instructions regarding the submission ofthese requests. Do not send these TARs to theregular Denti-Cal P.O.Box as they may be denied.

$1,800 Limit per Calendar Year for Beneficiary

Dental ServicesThe fiscal year (FY) 2005-2006 Budget Act requiredthe Department to employ changes in coveredbenefits as set forth in Assembly Bill 131 (Chapter 80,Statutes of 2005). Assembly Bill 131 amends Section14080 of the Welfare and Institutions Code bylimiting non-exempt dental services for beneficiaries21 years of age or older to $1,800 per beneficiary foreach calendar year.

To help reduce the possibility that procedures

performed will not be fully paid because the dentalcap has been reached, providers should:

verify the beneficiarys dental cap.

discuss with the beneficiary any othertreatment recently received from anotherprovider.quickly submit claims for procedures notrequiring prior authorization.upon receipt of a NOA, promptly performservices and submit requests for payment.

Providers are reminded that approval of a TAR does

not guarantee payment. Debits toward the dental capare based upon the order in which claims and NOAsare processed. Non-exempt services will be paid inthe order they are received and processed until theannual dental cap is reached for a calendar year.Providers may not bill beneficiaries when theprogram has paid any amount on a specific procedureas the result of the dental cap being met. This partialpayment on a procedure must be consideredpayment in full.Providers may only bill beneficiaries their usual,customary, and reasonable fees if the $1,800 limit percalendar year for dental services (dental cap) hasbeen met and nothing has been paid on a procedure.Payments will not be applied towards the $1,800 percalendar year limit for any of the following:1.2.3.4.5.6.

Pregnancy-Related ServicesEffective October 1, 2014, pregnant beneficiaries,regardless of age, aid code, and/or scope of benefitswill be eligible to receive all dental procedures listedin the Denti-Cal Manual of Criteria (MOC) that arecovered by the Medi-Cal program so long as all MOCprocedure requirements and criteria are met.Beneficiaries will also be eligible to receive theseservices for 60 days postpartum, including anyremaining days in the month in which the 60th dayfalls.If you receive a denial (Adjudication Reason Code503A or 503B) for a covered service for apregnant/postpartum beneficiary, you should submita Claim Inquiry Form (CIF) indicating PREGNANT orPOSTPARTUM in the REMARKS field plus anyadditional documentation and radiographs pertinentto the procedure for reconsideration.

Radiograph Requirements for Pregnant and

Postpartum BeneficiariesFor all procedures that require radiographs/priorauthorization, no payment will be made if theradiographs are not submitted. "Patient refused xrays" will not be acceptable documentation for nonsubmission of radiographs. Additional informationregarding dental care during pregnancy can be foundat the CDA Foundation web site athttp://www.cdafoundation.org/learn/educationtraining/perinatal-oral-health-education.

Long-Term CareBeneficiaries will be excluded from the dental cap ifthey have Long Term Care (LTC) aid codes or reside ineither Place of Service 4/SNF (Skilled Nursing Facility)or Place of Service 5/ICF (Intermediate Care Facility).Exempt long term aid codes include 13, 23, 53, and 63(for more information on Aid Codes, refer to the endof this section). Descriptions of these and other aidcodes are found in the following pages of this section.All other aid codes and procedure codes will besubject to the $1,800 calendar year limitation.

Third Quarter, 2016

Special Needs Patients

Special needs patients are defined as those patientswho have a physical, behavioral, developmental, oremotional condition that prohibits them fromadequately responding to a providers attempts toperform an examination.Patients may be classified as special needs when aprovider has adequately documented the specificcondition and the reasons why an examination andtreatment cannot be performed without general orintravenous sedation.Prior authorization is not required for treatment(with the exception of fixed partial dentures,removable prosthetics and implants) in order tominimize the risks associated with sedation.When treatment is performed without priorauthorization (on a procedure that normally wouldrequire prior authorization), requests for paymentmust be accompanied by documentation toadequately demonstrate the medical necessity. Referto the individual procedures for specific requirementsand limitations in Section 5: Manual of Criteria andSchedule of Maximum Allowances of this Handbook.

American Sign Language (ASL)

Translation ServicesAmerican Sign Language translation services areavailable to Denti-Cal beneficiaries. To request an ASLtranslator be present at the time of the appointment,either the provider or the beneficiary must contactDenti-Cal and provide the following information:

Date of dental appointment

Start and end time of appointmentAppointment type (dental, surgical, consult,etc.)Name of person needing ASL servicesOffice addressOffice contactOffice phone number

To schedule an ASL translator, providers can call the

Provider Customer Service Line at 1-800-423-0507.Beneficiaries can call the Free Beneficiary CustomerService Line at 1-800-322-6384.

Third Quarter, 2016

Treating Beneficiaries That Reside in Other

CountiesEnrolled Denti-Cal providers can treat any eligiblebeneficiary in the Denti-Cal program no matter wherethe beneficiary resides. Denti-Cal providers canprovide services to eligible beneficiaries that reside inother counties in addition to the county the provideris located. To check Medi-Cal eligibility of abeneficiary, please call the Automated EligibilityVerification System (AEVS) at (800) 456-2387.

TeledentistryThe Department of Health Care Services has opted topermit the use of teledentistry as an alternativemodality for the provision of select dental services.Therefore, enrolled Denti-Cal billing providers maysubmit documents for services rendered utilizingteledentistry.The goal of teledentistry is to:

Allow Medi-Cal providers to practice

teledentistry, as defined to mean thetransmission of medical information to bereviewed at a later time by a licensed dentalprovider at a distant site; andAuthorize modest scope of practiceexpansions.

Please note that allied dental professionals, such as

Registered Dental Hygienists in Alternative Practice,shall not be permitted to bill for services rendered viateledentistry.

Transmission TypesAsynchronous Store and ForwardAsynchronous store and forward is the transmissionof a beneficiary's dental information from a sitewhere a beneficiary is located at the time dentalservices are provided via a telecommunicationssystem or where the asynchronous store and forwardservice originates (i.e. "originating site") to a providerat a distant site, where the provider reviews theinformation-within 48 hours-without the beneficiarybeing present.A beneficiary receiving teledentistry services by storeand forward may also request to have real-timecommunication with the distant dentist at the time ofTreating BeneficiariesPage 4-11

the consultation or within 30 days of the original

consultation.Synchronous or Live TransmissionsSynchronous interaction, or live transmission, is areal-time interaction between a beneficiary and aprovider located at a distant site. Live transmissionsare limited to 90 minutes per beneficiary perprovider, per day. Please note: Live transmissions areonly to be used at the beneficiary's request.

Billing for Teledentistry

Billing for Asynchronous Storeand Forward (D0999)Teledentistry claims are identified using CurrentDental Terminology (CDT) code D0999 (Unspecifieddiagnostic procedure, by report) with a date ofservice on or after July 1, 2015. The Schedule ofMaximum Allowance (SMA) for D0999 used forteledentistry is $0.00.The following CDT codes may be billed as part ofteledentistry by enrolled Denti-Cal billing providers:

Providers may bill for teledentistry on the same claim

form as other types of procedure codes unless theyare in conflict with the Denti-Cal Manual of Criteria(MOC).Treating BeneficiariesPage 4-12

A claim service line containing procedure D0999, and

a date of service on or after July 1, 2015, will be paid$0.00. If a claim containing procedure D0999 is notfor teledentistry but for an unspecified diagnosticprocedure then Denti-Cal will re-evaluate the claimand modify it to an appropriate CDT procedure codeto be paid according to the SMA. If a providerreceives $0.00 for Procedure D0999 and theprocedure is not for teledentistry then the providermust submit a CIF for the claim explaining theprocedure is not for teledentistry. Providers must alsoinclude any documentation and/or information asspecified in the MOC for D0999.

Billing for Synchronous or

Live Transmissions (D9999)Providers may use CDT Code D9999 forreimbursement of live transmission costs associatedwith teledentistry (D0999). When submitting a claimfor reimbursement of live transmission costs, CDTCode D9999 will only be payable when CDT CodeD0999 has been rendered. Transmission costsassociated with store and forward are notreimbursable.The reimbursed rate is 24 cents per minute, up to amaximum of 90 minutes. Procedure D9999 may onlybe used once per date of service per beneficiary, perprovider. Written documentation is required andmust include the number of minutes the transmissionoccurred.Live transmissions are only billable at thebeneficiary's request. If the live transmission cannotoccur at the precise time of the beneficiary request,then a subsequent agreed upon time may bescheduled between the beneficiary and providerwithin a 30 day time period.

Third Quarter, 2016

Copayment Requirements for Denti-Cal Services

It is the providers responsibility to determine if a copayment is required according to the Denti-Cal criteria. Thecopayment, if applicable, should be collected by the provider at the time the dental services are performed. Eventhough the copayment may be required, the provider has the option of collecting or not collecting the copaymentamount.Copayment amounts are in addition to the usual Denti-Cal provider reimbursement. No deduction will be madefrom the amounts otherwise approved by Denti-Cal for payment to the provider.A provider is prohibited by law from denying dental services if a beneficiary cannot make the copayment. Thebeneficiary is, however, liable to the provider for any copayment amount owed. See Welfare and Institutions Code,Section 14134.For questions regarding these copayment provisions as they apply to dental services, please contact Denti-Cal tollfree at (800) 423-0507.MEDI-CAL COPAYMENT CRITERIASERVICES SUBJECT TO COPAYMENT

COPAYMENT FEE EXCEPTIONS TO FEE

NON-EMERGENCY SERVICES PROVIDED IN AN

EMERGENCY ROOM:A non-emergency service is defined as any service notrequired for alleviation of severe pain or the immediatediagnosis and treatment of severe medical conditionswhich, if not immediately diagnosed and treated, wouldlead to disability or death. Such services provided in anemergency room are subject to copayment.

Third Quarter, 2016

Persons aged 18 or under.

Any woman receivingperinatal care (servicespregnancy and one monthfollowing delivery).Persons who are inpatients ina health facility (hospital,skilled nursing facility orintermediate care facility).Any child in AFDC-foster care.Any service for which theprograms payment is $10 orless.

All listed above, plus person aged

65 or older.

Treating BeneficiariesPage 4-13

Emergency Services

51159(b), to review the medical necessity of

emergency services provided to beneficiaries.The Department may require providers to followthe procedures for obtaining authorization on aretroactive basis as the process for imposingpost-service prepayment audits. Requests forretroactive authorization of emergency servicesmust adequately document the medial necessityof the services and must justify why the servicesneeded to be rendered on an emergency basis.

Title 22, CCR, Section 51056, states as follows:

(a) Except as provided in subsection (b),emergency services means those servicesrequired for alleviation of severe pain, orimmediate diagnosis and treatment of unforeseenmedical conditions, which, if not immediatelydiagnosed and treated, would lead to disability ordeath.(b) For purposes of providing treatment of anemergency medical condition to otherwise eligiblealiens pursuant to Welfare and Institutions CodeSection 14007.5(d), emergency medicalcondition means a medical condition (includingemergency labor and delivery) manifesting itself byacute symptoms of sufficient severity, includingsevere pain, such that the absence of immediatemedical attention could reasonably be expected toresult in any of the following:

(d) Program limitation set forth in Section 51304

and 51310 are not altered by this section.Within the scope of dental benefits under theprogram, emergency services may comprise of thosediverse professional services required in the event ofunforeseen medical conditions such as hemorrhage,infection, or trauma. Examples of emergencyconditions may include, but are not limited to, thefollowing:

(1) Placing the patient's health in serious

jeopardy.

(2) Serious impairment to bodily functions.

(3) Serious dysfunction of any bodily organ or

part.(c)Emergency services are exempt from priorauthorization, but must be justified according tothe following criteria:

High risk-to-life or seriously disabling

conditions, such as cellulitis, oralhemorrhage, and traumatic conditions.Low risk-to-life or minimally disablingconditions, such as painful low grade oraldental infections, near pulpal exposures,fractured teeth or dentures, where thesesconditions are exacerbated by psychiatric orother neurotic states of the patient.

(1) Any service classified as an emergency,

which would have been subject to priorauthorization had it not been so classified, mustbe supported by a physicians, podiatrists ordentists statement which describes the natureof the emergency including relevant clinicalinformation about the patients condition, andstates why the emergency services renderedwere considered to be immediately necessary. Amere statement that an emergency existed isnot sufficient. It must be comprehensive enoughto support a finding that an emergency existed.Such statement shall be signed by a physician,podiatrist or dentist who had direct knowledgeof the emergency described in this statement.(2) The Department may impose post serviceprepayment audit as set forth in SectionTreating BeneficiariesPage 4-14

Third Quarter, 2016

Table 4: Omnibus Budget Reconciliation Act

(OBRA) Emergency Services Only OmnibusBudget Reconciliation Act (OBRA) EmergencyServices OnlyOBRA beneficiaries are newly legalized amnestyaliens and/or undocumented aliens who areotherwise eligible for Medi-Cal benefits but are notpermanent U.S. residents. These beneficiaries havelimited benefits and are only eligible for emergencydental services; they can be identified by their limitedscope aid code.An emergency dental condition is a dental conditionmanifesting itself by acute symptoms of sufficientseverity including severe pain, which in the absenceof immediate dental attention could reasonably beexpected to result in any of the following:

placing the patients health in serious

When applicable, necessary documentation and/or

radiographs to justify the emergency procedure mustbe submitted with the claim.When the procedures listed above are provided, anemergency certification statement is always required.This statement must be either entered in theComments area (Field 34) on the claim form orattached to the claim. It must:1.

2.3.

Describe the nature of the emergency, including

clinical information pertinent to the patientscondition; andExplain why the emergency services providedwere considered immediately necessary.The statement must be signed by the dentistproviding the services (in the Comments areaor on the attached statement) and must provideenough information to show the existence of anemergency dental condition and need forimmediate treatment. Merely stating anemergency existed or that the patient was inpain is insufficient.

Third Quarter, 2016

Treating BeneficiariesPage 4-15

Other Health Coverage

The Denti-Cal program follows the regulations inCalifornia Code of Regulations (CCR), Title 22, whichrequire full utilization of benefits from all othercarriers first. This means Denti-Cal is considered thesecondary carrier and can only pay up to themaximum amount allowed for covered benefits.Denti-Cal will make payment only if the primarycarrier pays less than the maximum Denti-Calallowance.After billing the other coverage carrier, providersshould submit a claim to Denti-Cal along with theExplanation of Benefits/Remittance Advice (EOB/RA),Proof of Denial letter, or fee schedule from the otherinsurance carrier. Denti-Cal will not accept no otherdental coverage written on the claim, NOA forpayment, RTD or CIF. Denti-Cal will apply thecoinsurance or deductible to each service in theindividual amounts indicated on the EOB/RA and feeschedule; if the other coverage carrier has applied thecoinsurance/deductible amount to the claim as awhole, Denti-Cal will distribute the amount equallyamong all services listed on the claim whencalculating payment for covered services. Denti-Calwill pay the difference between the amount the othercoverage carrier paid for the service plus theappropriate coinsurance/deductible amount appliedto that service, and the Denti-Cal allowed amount forthe service.Note: Insurance information must be submitted for aclaim for payment, but is not required for a TAR.

Prepaid Health Plan (PHP)/Health

Maintenance Organization (HMO)When a Medi-Cal beneficiary has a PHP or HMO asother health coverage, he or she must use the planfacilities for regular dental care. Providers should billthe appropriate carrier for out-of-area services oremergency treatment covered by the beneficiary'sPHP or HMO.

The following are other health coverage codes:

OHC Health Coverage Type9Healthy FamiliesAPay and ChaseCCHAMPUSDMedicare Part DFMedicare HMOKKaiserLDental OnlyNNo Other CoveragePPHP/HMOVFee-For-Service CarriersProviders should note that even though the otherhealth coverage code indicates a PHP/HMO, thedental carrier may not be a PHP or HMO.For Denti-Cal to correctly process claims submittedfor payment, a Remittance Advice/Explanation ofBenefits (RA/EOB), fee schedule or denial of serviceletter must accompany the claim to verify the othercoverage carrier is a PHP/HMO. Providers billingDenti-Cal for services not included in the beneficiarysPHP/HMO plan must submit an RA/EOB, fee scheduleor denial letter showing that the PHP/HMO was billedfirst.

Child Health and Disability Prevention

(CHDP) GatewayOn July 1, 2003, Child Health and DisabilityPrevention (CHDP) medical providers (not dentalproviders) began pre-enrolling eligible low-incomechildren under 19 years of age into the new CHDPGateway. CHDP Gateway providers encourageparents to apply for health care coverage for theirchildren through Medi-Cal or Healthy Families. Thechildren are eligible to receive Full Scope, fee-forservice Medi-Cal and Denti-Cal benefits during themonth of application and the following month, oruntil the processing of their application is complete.Denti-Cal reimbursement rates for children eligiblefor this temporary coverage are the same as the usualDenti-Cal rates. Children who are not eligible foreither program will continue to receive CHDP servicesin accordance with the CHDP periodicity table.Since the Gateway began, several issues have arisenthat may be of interest to Denti-Cal providers:

Treating BeneficiariesPage 4-16

Because some children may be eligible for

only 1-2 months, it is very important forThird Quarter, 2016

children with temporary Medi-Cal eligibility

to be seen as quickly as possible. A numberof offices and clinics have responded bysetting aside a block of time to see thesechildren.Children enrolled through the Gateway willordinarily receive their BIC ID card within 10days of enrollment. In the interim, they willhave an immediate eligibility document,which will be either a copy of a printoutfrom an Internet Web site or a Point ofService (POS) device receipt similar to a gasstation pump receipt. This documentdisplays the beneficiary's BIC ID number andis an acceptable form of identification thatshould be accepted until the BIC ID card isreceived. Regardless of whether thebeneficiary presents a BIC ID card or a paperimmediate eligibility document, allproviders, including Childrens TreatmentProgram (CTP) providers, must always checka beneficiary's eligibility status at each visit.The PM160 form is insufficientdocumentation for participation in the CHDPGateway.The immediate eligibility document cancontain several different responses, so it isimportant to read the response carefully. Allproviders participating in the CHDP Gateway,including CTP providers, must checkeligibility for every beneficiary at every visit,regardless of what the response says. ThePM160 form is insufficient.Children who are determined ineligible fortemporary Medi-Cal coverage through theGateway may be assigned other emergencyor pregnancy-related Medi-Cal aid codes. If achild switches dentists because they wereunable to complete treatment prior totermination of their temporary Medi-Calcoverage, Denti-Cal encourages the childsprovider to provide the child's treatmentplan and radiographs to their new dentist toprevent unnecessary duplication of costs.Because of the short period of eligibility forsome children, Denti-Cal encouragesproviders to allow their names and phonenumbers to be distributed to CHDP medical

Third Quarter, 2016

providers. Providers willing to do this should

call the local CHDP office to be included on areferral list. Access the local CHDP office athttp://ww2.dhcs.ca.gov/services/chdp/Pages/default.aspx. Also, if Denti-Cal providersare able to accommodate children eligiblefor the Gateway on short notice, notify theCHDP medical providers so they will know ofyour willingness to see these childrenrelatively quickly. (For additional eligibilityprocedures for CHDP visit the following website:http://files.medi-cal.ca.gov/pubsdoco/publications/Masters-other/verifone/eligtrans_ver00.pdf.)

Altered Cards and Other Abuses of

the Denti-Cal Program Fraud, HelpStop:Altered Cards and Other AbusesThe Department is requesting that dental providersbe reminded that all beneficiary information isconfidential and must be protected from disclosureto unauthorized personnel. Beneficiary identificationincludes the following:

Protecting confidential information is especially

important for providers of inpatient care billing andthird-party insurance organizations when utilizingindependent billing agencies, as well as employeeswho appear to be inappropriately accessing suchinformation.Dental providers should not accept any Medi-Calidentification card that has been altered in any way. Ifa beneficiary presents a paper or plastic card that isphotocopied or contains erasures, strike-outs, whiteouts, type-overs, or appears to have been altered inany other way, the provider should request that thebeneficiary obtain a new card from his or her countysocial services office prior to performing services.Health care providers are encouraged to reportevidence of fraud to the Attorney Generals MedicalFraud Hotline at (800) 722-0432. Any provider whoTreating BeneficiariesPage 4-17

suspects a beneficiary of abusing the Denti-Cal

program may call (800) 822-6222. Situations whereabuse of the program may be suspected include:

Use of another person's Medi-Cal

Misuse of Benefits Identification Card

The Departments Medical Review Branch hasincreased the number of replacement Medi-CalBenefits Identification Cards (BICs) in an ongoingeffort to nullify BICs that may have been stolen ormisused. This process may be further escalated asother misuses of BICs are discovered.If a provider receives a response during the eligibilityverification process that states current BIC ID andissue date required, the provider must ask thebeneficiary for his/her new card.Attaching a copy of the BIC card for documentationpurposes will not be accepted.

Prevention of Identity Theft

To prevent identity theft, the Department requires allproviders to avoid using a beneficiarys Social SecurityNumber (SSN) whenever possible, and reminds themthat SSNs are not permitted on forms submitted forpayment. Claims or TARS submitted with SSNs will bedenied.When submitting TAR/Claim forms to Denti-Cal,providers should use the 14-character ID numberfrom the BIC.

Treating BeneficiariesPage 4-18

Third Quarter, 2016

Beneficiary Complaint orGrievance ProceduresA Medi-Cal beneficiary with a complaint or grievanceconcerning scope of benefits, quality of care,modification or denial of a TAR/Claim form, or otheraspect of services provided under the Denti-CalProgram must direct the complaint or grievance asfollows:

Initial Appeal to Provider

The beneficiary should initiate action by submittingthe complaint or grievance to the provider,identifying the complaint or grievance by specificallydescribing the disputed service, action, or inaction.The provider responsible for the dental needs of thebeneficiary should attempt to resolve the complaintor grievance within the parameters of the Denti-Calprogram.

Notification to Denti-CalWhen action at the provider level fails to resolve thecomplaint or grievance, the beneficiary shouldtelephone Denti-Cal at (800) 322-6384, identifyhimself/herself and the provider involved, andspecifically describe the disputed services, action, orinaction. The beneficiary may also complete theBeneficiary Medi-Cal Dental Program Complaint Form(a sample, found on the following pages, is to becopied for the beneficiary) and return it to Denti-Calat the address indicated on the form.

When a copy of the beneficiarys chart and other

pertinent information is requested from a providersoffice, it is important that this information besubmitted to Denti-Cal within the time frameindicated on the request to avoid potentialrecoupment of funds previously paid for theservice(s) at issue.Denti-Cal will send a letter summarizing its conclusionand reasons substantiating the decision to the patientwithin 30 days of the receipt of the complaint orgrievance. If it is determined that there is a need torecoup funds for previously paid service(s), Denti-Calwill issue the provider a written notification indicatingthe specific reasons for the recoupment.If a beneficiary is not able to make his/her scheduledclinical screening the 30 days may be extended.If a beneficiary is not satisfied with the decision of thecomplaint review process, he/she may ask for a StateHearing by writing to or calling:Office of the Chief Administrative Law JudgeState Department of Social ServicesPO Box 13189 Sacramento, CA 95813-3189Or:(800) 952-5253The following three pages include the forms tosubmit for beneficiary complaints. The 3rd, blankpage is for comments relating to the complaint.

Denti-Cal Beneficiary Services will make every effort

to resolve the problem at this level. Denti-Cal mayrefer the beneficiary back to the provider forresolution of the problem, or send the BeneficiaryMedi-Cal Dental Program Complaint Form to thebeneficiary for completion.Denti-Cal will acknowledge the written complaint orgrievance within five (5) calendar days of receipt. Thewritten complaint or grievance may be referred to aDenti-Cal dental consultant, who will determine thenext course of action, which could include contactingthe patient and/or provider, referring the patient to aclinical screening examination by a Denti-Cal ClinicalScreening Dentist, or referral to the appropriate peerreview body.

Third Quarter, 2016

Treating BeneficiariesPage 4-19

Beneficiary Medi-Cal Dental Program Complaint Form (Page 1)

Beneficiary Medi-Cal Dental Program Complaint Form

Treating BeneficiariesPage 4-20

Third Quarter, 2016

Beneficiary Medi-Cal Dental Program Complaint Form (Page 2)

Third Quarter, 2016

Treating BeneficiariesPage 4-21

Beneficiary Medi-Cal Dental Program Complaint Form (Blank)

Treating BeneficiariesPage 4-22

Third Quarter, 2016

Grievance and Complaint Procedures to the

Department of Managed Health CareGrievance and complaint procedures for bothbeneficiaries and providers are maintained in order toresolve or adjudicate differences in professionaljudgments or opinions, misunderstandings in priorauthorization or payment policies, and interpretationof the level and scope of benefits of the Denti-Calprogram.For more information visit the California Departmentof Managed Health Care (DMHC) Web site:http://www.dmhc.ca.gov/aboutthedmhc/.The following page contains information on how tofile a complaint with the DMHC.

Third Quarter, 2016

Treating BeneficiariesPage 4-23

Notice from the Department of Managed Health Care (How to File a Complaint with DMHC)

Treating BeneficiariesPage 4-24

Third Quarter, 2016

Granted Decision

State HearingAccording to California Code of Regulations (CCR),Title 22, Section 50951:Applicants or beneficiaries shall have the right to aState hearing if dissatisfied with any action orinaction of the county department, the Departmentof Health Services or any person or organizationacting in behalf of the county or [t]he Departmentrelating to Medi-Cal eligibility or benefits.

Authorization of Services Through the State

Hearing ProcessServices can be authorized through the State Hearingprocess in two ways:1.2.

A conditional withdrawal; orA granted decision.

Conditional WithdrawalA conditional withdrawal can be offered to thebeneficiary upon receipt of additional informationfrom either the beneficiary or the dentist. If thebeneficiary agrees to the conditions of thewithdrawal, a pink authorization letter is mailed tohim/her. The beneficiary may then take theauthorization to the Denti-Cal provider of his/herchoice. In order to be paid for services provided, thetreating provider is responsible to:1.2.3.4.

Be an enrolled Denti-Cal provider.

Verify the patients eligibility.Provide ONLY the service(s) authorized withinthe 180 days of the date on the letter.Submit a claim for payment within 60 calendardays from the date of the last completed serviceprovided within the authorization period. Theclaim must include the original pink authorizationletter bearing the original signature. Mail theclaim for payment to:

If an administrative law judge determines a denied

service should be authorized, the judge will issue aGRANTED DECISION. Through the action, thebeneficiary is authorized to take the decision to theDenti-Cal provider of his/her choice to receiveservices. In order to be paid for services provided, thetreating provider is responsible to:1.2.3.

4.

Be an enrolled Denti-Cal provider.

Verify the patients eligibility.Provide ONLY the service(s) authorized in theORDER section of the decision within 180calendar days of the signed order.Submit a claim for payment within 60 calendardays from the date of the last completed serviceperformed within the authorization period. Theclaim must include the Granted Decision andshould be mailed to the following address:Denti-CalCalifornia Medi-Cal ProgramAttn: State HearingsPO Box 13898Sacramento, CA 95853

Contacting Denti-Cal to Postpone or

Withdraw a State HearingThe Department of Social Services (DSS) hasimplemented a phone number for providers andbeneficiaries wishing to postpone or withdraw a StateHearing. The toll free phone number is (855) 2661157. This number may also be used to make ageneral inquiry about a State Hearing that has alreadybeen filed.To make an oral request to file a State Hearing,providers and beneficiaries should continue to callDSS toll free at (800) 952-5253.

Third Quarter, 2016

Treating BeneficiariesPage 4-25

Aid CodesThe following aid codes identify the types of services for which different Medi-Cal/CMSP/CCS/GHPP beneficiariesare eligible.More information about OBRA and IRCA aid codes can be found on www.medi-cal.ca.gov > Publications > ProviderManuals > Part 1-Medi-Cal Program and Eligibility > OBRA and IRCA (obra).Special Indicators: These indicators, which appear in the aid code portion of the county ID number, help Medi-Calidentify the following:IE

Ineligible: A person who is ineligible for Medi-Cal benefits in the case. An IE person may only use medicalexpenses to meet the SOC for other family members associated within the same case. Upon certification ofthe SOC, the IE individual is not eligible for Medi-Cal benefits in this case. An IE person may be eligible forMedi-Cal benefits in another case where the person is not identified as IE.

RR

Responsible Relative: An RR is allowed to use medical expenses to meet the SOC for other family membersfor whom he/she is responsible. Upon certification of the SOC, an RR individual is not eligible for Medi-Calbenefits in this Medi-Cal Budget Unit (MBU). The individual may be eligible for Medi-Cal benefits inanother MBU where the person is not identified as RR.

AidCode

SOC

Program/Description

0A

Full Scope

Benefits

No

Refugee Cash Assistance (FF). Includes unaccompanied children. Covers

all eligible refugees during their first eight months in the United States.Unaccompanied children are not subject to the eighth-month limitationprovision. This population is the same as aid code 01, except that theyare exempt from grant reductions on behalf of the Assistance PaymentsDemonstration Project/California Work Pays Demonstration Project.

0C

HF services only (no

Medi-Cal)

No

Access for Infants and Mothers (AIM) - Infants enrolled in Healthy

Families (HF). Infants from a family with an income of 200 to 300percent of the federal poverty level, born to a mother enrolled in AIM.The infants enrollment in the HF program is based on their mothersparticipation in AIM.

0E

Full Scope

No

Medi-Cal Access Prog Preg Women >213% through 322%

0F

Full Scope

No

Five Month transitional food stamp program. This aid code is forhouseholds who are terminating their participation in the CalWORKsprogram without the need to re-establish food stamp eligibility.

0M

Full Scope

No

Accelerated Enrollment (AE) of temporary, full scope, no Share of Cost

(SOC) Medi-Cal only for females 65 years of age and younger, who arediagnosed with breast and/or cervical cancer, found in need oftreatment, and who have no creditable health insurance coverage.Eligibility is limited to two months because the individual did not enrollfor on-going Medi-Cal.

0N

Full Scope

No

AE of temporary, Full Scope, no SOC Medi-Cal coverage only for females

65 years of age and younger, who are diagnosed with breast and/orcervical cancer, found in need of treatment, and who have nocreditable health insurance coverage. No time limit.

Treating BeneficiariesPage 4-26

Third Quarter, 2016

AidCode

Benefits

SOC

Program/Description

0P

Full Scope

No

Full scope, no SOC Medi-Cal only for females 65 years of age andyounger who are diagnosed with breast and/or cervical cancer andfound in need of treatment; who have no creditable health insurancecoverage and who are eligible for the duration of treatment.

0R

Restricted Services

No

Provides payment of premiums, co-payments, deductibles and

coverage for non-covered cancer-related services for all males andfemales (regardless of age or immigration status). These individualsmust have high cost other health coverage cost-sharing insurance (over$750/year), have a diagnosis of breast (payment limited to 18 months)and/or cervical (payment limited to 24 months) cancer, and are foundin need of treatment.

0T

Restricted Services

No

Provides payment of 18 months of breast and 24 months of cervical

cancer treatment services for all aged males and females who are noteligible under aid codes 0P, 0R, or 0U, regardless of citizenship, that arediagnosed with breast and/or cervical cancer and found in need oftreatment. This aid code does not contain anyone with other creditablehealth insurance, regardless of the amount of coinsurance. Does notcover individuals with expensive creditable insurance or anyone withunsatisfactory immigration status.

0U

Restricted Services

No

Provides services only for females with unsatisfactory immigration

status, who are 65 years of age or younger, diagnosed with breastand/or cervical cancer and are found in need of treatment. Theseindividuals are eligible for federal Breast and Cervical Cancer TreatmentProgram (BCCTP) for emergency services for the duration of theindividuals treatment. State-only breast (payment limited to 18months) and cervical (payment limited to 24 months) cancer services,pregnancy-related services and LTC services. Does not cover individualswith other creditable health insurance.

0V

Limited Scope

No

Provides Emergency, Long Term Care, and Pregnancy-related services,

with no share of cost, to individuals no longer eligible for the Breast andCervical Cancer Treatment Program.

01

Full Scope

No

Refugee Cash Assistance (FFP). Includes unaccompanied children.

Covers all eligible refugees during their first eight months in the UnitedStates. Unaccompanied children are not subject to the eighth-monthlimitation provision.

02

Full Scope

Y/N

Refugee Medical Assistance/Entrant Medical Assistance (FFP). Covers

refugees and entrants who need Medi-Cal and who do not qualify for orwant cash assistance.

03

Full Scope

No

Adoption Assistance Program (AAP) (FFP). A cash grant program to

facilitate the adoption of hard-to-place children who would requirepermanent foster care placement without such assistance.

SERIOUSLY EMOTIONALLY DISTURBED CHILDREN

Third Quarter, 2016

A cash grant program to facilitate the ongoing adoptive placement of

hard-to-place NMDs, whose initial AAP payment occurred on or afterage 16 and are over age 18 but under age 21, who would requirepermanent foster care placement without such assistance.

08

Full Scope

No

Entrant Cash Assistance (ECA) (FFP). Provides ECA benefits to

Cuban/Haitian entrants, including unaccompanied children who areeligible, during their first eight months in the United States. (Forentrants, the month begins with their date of parole.) Unaccompaniedchildren are not subject to the eighth-month limitation provision.

09

None

No

FOOD STAMP PROGRAM - PARTICIPANTS

1A

None

No

Aged Cash Assistance Program for Immigrants (CAPI) Qualified Aliens

1D

Full Scope

No

Aged In-Home Support Services (IHSS). Covers aged individuals

discontinued from the IHSS residual program for reasons other than theloss of Supplemental Security Income/State Supplemental Payment(SSI/SSP) until the county determines their Medi-Cal eligibility.

1E

Full Scope

No

Craig v. Bonta Continued Eligibility for the Aged. Aid Code 1E coversformer SSI beneficiaries who are aged (with the exception of personswho are deceased or incarcerated in a correctional facility) until thecounty redetermines their Medi-Cal eligibility. Provides fee-for-servicefull scope Medi-Cal without a share of cost and with federal financialparticipation.

Restricted Federal Poverty Level Aged (Restricted FPL-Aged). Provides

emergency and pregnancy-related benefits (no Share of Cost) toqualified aged individuals/couples who do not have satisfactoryimmigration status.

1X

Full Scope

No

Multipurpose Senior Services Program (MSSP) waiver provides full

scope benefits, MSSP transitional and non-transitional services, with noshare of cost and with federal financial participation.

1Y

Full Scope

Yes

Multipurpose Senior Services Program (MSSP) waiver provides full

scope benefits, MSSP transitional and non-transitional services, with aShare of Cost and with federal financial participation.

10

Full Scope

No

SSI/SSP Aid to the Aged (FFP). A cash assistance program administered

by the SSA which pays a cash grant to needy persons 65 years of age orolder.

11

None

No

AID TO THE AGED - SERVICES ONLY

12

None

No

AID TO THE AGED - SPECIAL CIRCUMSTANCES

13

Full Scope

Y/N

Aid to the Aged LTC (FFP). Covers persons 65 years of age or olderwho are medically needy and in LTC status.

Treating BeneficiariesPage 4-28

Third Quarter, 2016

AidCode

SOC

Program/Description

14

Full Scope

Benefits

No

Aid to the Aged Medically Needy (FFP). Covers persons 65 years of

age or older who do not wish or are not eligible for a cash grant, but areeligible for Medi-Cal only.

16

Full Scope

No

Aid to the Aged Pickle Eligibles (FFP). Covers persons 65 years of ageor older who were eligible for and receiving SSI/SSP and Title II benefitsconcurrently in any month since April 1977 and were subsequentlydiscontinued from SSI/SSP but would be eligible to receive SSI/SSP iftheir Title II cost-of-living increases were disregarded. These personsare eligible for Medi-Cal benefits as public assistance recipients inaccordance with the provisions in the Lynch v. Rank lawsuit.

17

Full Scope

Yes

Aid to the Aged Medically Needy, SOC (FFP). Covers persons 65 yearsof age or older who do not wish or are not eligible for a cash grant, butare eligible for Medi-Cal only. SOC required.

18

Full Scope

No

Aid to the Aged IHSS (FFP). Covers aged IHSS cash recipients, 65 yearsof age or older, who are not eligible for SSI/SSP cash benefits.

2A

Full Scope

No

Abandoned Baby Program. Provides Full Scope benefits to children up

to three months of age who were voluntarily surrendered within 72hours of birth pursuant to the Safe Arms for Newborns Act.

2C

No Dental

No

CCHIP 266% - 322%, 0 =< 19

2D

Full Scope

BLIND DISCONTINUED IHSS RESIDUAL

2E

Full Scope

No

Craig v. Bonta Continued Eligibility for the Blind. Aid code 2E coversformer SSI beneficiaries who are blind (with the exception of personswho are deceased or incarcerated in a correctional facility) until thecounty redetermines their Medi-Cal eligibility. Provides fee-for-servicefull scope Medi-Cal without a share of cost and with federal financialparticipation.

2F

None

Yes

PERSONAL CARE SERVICES PROGRAM

2H

Full Scope

No

Blind - Federal Poverty Level - Full

2L

None

N/A

IHSS - PLUS WAIVER

2M

None

N/A

IHSS - PERSONAL SERVICES

2N

None

N/A

IHSS - RESIDUAL

2V

Full Scope

No

TVCAP RMA Medi-Cal NO SOC

2P

Full Scope

No

ARC Program - Medi-Cal coverage for foster children and youth up to 18

years of age (eligibility ends on the last day of the month of their 18thbirthday) participating in the ARC Program who do not qualify for stateCalWORKs.

2R

Full Scope

No

ARC Program - Non-Minor Dependent (NMD) - Medi-Cal coverage for

foster youth 18 to 21 years of age (eligibility ends on the last day of themonth of their 21st birthday) participating in the ARC Program as aNMD who does not qualify for state CalWORKs.

Third Quarter, 2016

Formatted: Strong, Font: Not Bold

Treating BeneficiariesPage 4-29

AidCode

SOC

Program/Description

2S

Full Scope

Benefits

No

ARC Program - Federal CalWORKs - Medi-Cal coverage for foster

children and youth up to 18 years of age (eligibility ends on the last dayof the month of their 18th birthday) participating in the ARC Programwho qualify for federal CalWORKs.

2T

Full Scope

No

ARC Program - State CalWORKs - Medi-Cal coverage for foster children

and youth up to 18 years of age (eligibility ends on the last day of themonth of their 18th birthday) participating in the ARC Program whoqualify for state CalWORKs.

2U

Full Scope

No

ARC Program - State CalWORKs NMD - Medi-Cal coverage for foster

youth 18 to 21 years of age (eligibility ends on the last day of the monthof their 21st birthday) participating in the ARC Program as a NMD whoqualifies for state CalWORKs.

LIMITED TERM REINSTATEMENT

by the SSA, which pays a cash grant to needy blind persons of any age.

21

None

No

AID TO THE BLIND - SERVICES ONLY

22

None

No

AID TO THE BLIND - SPECIAL CIRCUMSTANCES

23

Full Scope

Y/N

Aid to the Blind LTC Status (FFP). Covers persons who meet thefederal criteria for blindness, are medically needy, and are in LTC status.

24

Full Scope

No

Aid to the Blind Medically Needy (FFP). Covers persons who meet thefederal criteria for blindness who do not wish or are not eligible for acash grant, but are eligible for Medi-Cal only.

26

Full Scope

No

Aid to the Blind Pickle Eligibles (FFP). Covers persons who meet thefederal criteria for blindness and are covered by the provisions of theLynch v. Rank lawsuit. (See Aid Code 16 for definition of Pickle eligibles.)

27

Full Scope

Yes

Aid to the Blind Medically Needy, SOC (FFP). Covers persons whomeet the federal criteria for blindness who do not wish or are noteligible for a cash grant, but are eligible for Medi-Cal only. SOC isrequired of the beneficiaries.

28

Full Scope

No

Aid to Blind IHSS (FFP). Covers persons who meet the federaldefinition of blindness and are eligible for IHSS. (See Aid Code 18 fordefinition of eligibility for IHSS.)

This program provides for continued cash and Denti-Cal coverage ofchildren whose parents have been discontinued from cash aid andremoved from the assistance unit (AU) due to reaching the CalWORKs60-month time limit without needing a time extender exception.

3C

Full Scope

No

Safety Net - Two-Parent, CalWORKs Timed-Out, Child-Only Case. This

program provides for continued cash and Denti-Cal coverage of childrenwhose parents have been discontinued from cash aid and removedfrom the AU due to reaching the CalWORKs 60-month time limitwithout meeting a time extender extension.

Treating BeneficiariesPage 4-30

Third Quarter, 2016

AidCode

SOC

Program/Description

3D

Full Scope

Benefits

No

CalWORKs Pending, Medi-Cal Eligible. Provides Medi-Cal coverage for a

maximum period of four months to new CalWORKs recipients.

3E

Full Scope

No

CalWORKs LEGAL IMMIGRANT FAMILY GROUP (FFP). Provides aid to

families in which a child is deprived because of the absence, incapacityor death of either parent.

3F

Full Scope

No

Two Parent Safety Net & Drug/Fleeing Felon Family.

3G

Full Scope

No

AFDC-FG (State only) (non-FFP cash grant FFP for Medi-Cal eligibles).Provides aid to families in which a child is deprived because of theabsence, incapacity or death of either parent, who does not meet allfederal requirements, but State rules require the individual(s) be aided.This population is the same as Aid Code 32, except that they areexempt from the AFDC grant reductions on behalf of the AssistancePayments Demonstration Project/California Work Pays DemonstrationProject.

3H

Full Scope

No

AFDC-FU (State only) (non-FFP cash grant FFP for Medi-Cal eligibles).Provides aid to pregnant women (before their last trimester) who meetthe federal definition of an unemployed parent but are not eligiblebecause there are no other children in the home. This population is thesame as Aid Code 33, except that they are exempt from the AFDC grantreductions on behalf of the Assistance Payments DemonstrationProject/California Work Pays Demonstration Project.

3J

None

CalWORKs Diversion AF

3K

None

CalWORKs Diversion 2P

3L

Full Scope

No

CalWORKs LEGAL IMMIGRANT FAMILY GROUP (FFP). Provides aid to

families in which a child is deprived because of the absence, incapacityor death of either parent.

3M

Full Scope

No

CalWORKs LEGAL IMMIGRANT UNEMPLOYED (FFP). Provides aid to

families in which a child is deprived because of the unemployment of aparent living in the home.

3N

Full Scope

No

AFDC Mandatory Coverage Group Section 1931(b) (FFP). Section 1931

requires Medi-Cal be provided to low-income families who meet therequirements of the Aid to Families with Dependent Children (AFDC)State Plan in effect July 16, 1996.

3P

Full Scope

No

AFDC Unemployed Parent (FFP cash) Aid to families in which a child is

deprived because of the unemployment of a parent living in the homeand the unemployed parent meets all federal AFDC eligibilityrequirements. This population is the same as Aid Code 35, except thatthey are exempt from the AFDC grant reductions on behalf of theAssistance Payments Demonstration Project/California Work PaysDemonstration Project.

Third Quarter, 2016

Treating BeneficiariesPage 4-31

AidCode

Benefits

SOC

Program/Description

No

Aid to Families with Dependent Children (AFDC) Family Group (FFP) in

which the child/children is/are deprived because of the absence,incapacity or death of either parent. This population is the same as AidCode 30, except that they are exempt from the AFDC grant reductionson behalf of the Assistance Payments Demonstration Project/CaliforniaWork Pays Demonstration Project.

3R

Full Scope

3S

None

3T

Restricted to pregnancyand emergency services

No

Initial Transitional Medi-Cal (TMC) (FFP). Provides six months of

emergency and pregnancy-related initial TMC benefits (no SOC) foraliens who do not have satisfactory immigration status (SIS) and havebeen discontinued from Section 1931(b) due to increased earnings fromemployment.

3U

Full Scope

No

CalWORKs LEGAL IMMIGRANT UNEMPLOYED (FFP). Provides aid to

families in which a child is deprived because of the unemployment of aparent living in the home.

3V

Restricted to pregnancyand emergency services

No

Section 1931(b) (FFP). Provides emergency and pregnancy-related

benefits (no SOC) for aliens without SIS who meet the income,resources and deprivation requirements of the AFDC State Plan in effectJuly 16, 1996.

3W

Full Scope

No

Temporary Assistance for Needy Families (TANF) -Timed out, mixed

case. Recipients who reach the TANF 60-month time limit, remaineligible for CalWORKs and the family includes at least one non-federallyeligible recipient.

3X

None

CalWORKs Diversion 2P State only

3Y

None

CalWORKs Diversion 2P State only

30

Full Scope

No

AFDC-FG (FFP). Provides aid to families with dependent children in a

family group in which the child/children is/are deprived because of theabsence, incapacity or death of either parent.

31

None

No

AFDC FAMILY GROUP - SERVICES ONLY

32

Full Scope

No

TANF-Timed out. Recipients who have reached their TANF 60-month

time limit and remain eligible for CalWORKs.

33

Full Scope

No

AFDC Unemployed Parent (State-only program) (non-FFP cash grant

FFP for Medi-Cal eligibles). Provides aid to pregnant women (beforetheir last trimester) who meet the federal definition of an unemployedparent but are not eligible because there are no other children in thehome.

34

Full Scope

No

AFDC-MN (FFP). Covers families with deprivation of prenatal care or

support who do not wish or are not eligible for a cash grant but areeligible for Medi-Cal only.

35

Full Scope

No

AFDC-U (FFP cash). Provides aid to families in which a child is deprived

because of unemployment of a parent living in the home, and theunemployed parent meets all federal AFDC eligibility requirements.

Treating BeneficiariesPage 4-32

CA Registered Domestic Partner

Third Quarter, 2016

AidCode

Benefits

SOC

Program/Description

36

Full Scope

No

Aid to Disabled Widow/ers (FFP). Covers persons who began receiving

Title II SSA before age 60 who were eligible for and receiving SSI/SSPand Title II benefits concurrently and were subsequently discontinuedfrom SSI/SSP but would be eligible to receive SSI/SSP if their Title IIdisabled widow/ers reduction factor and subsequent COLAs weredisregarded.

37

Full Scope

Yes

AFDC-MN (FFP). Covers families with deprivation of prenatal care or

support who do not wish or are not eligible for a cash grant, but areeligible for Medi-Cal only. SOC required of the beneficiaries.

38

Full Scope

No

Continuing Medi-Cal Eligibility (FFP). Edwards v Kizer court order

provides for uninterrupted, no SOC Medi-Cal benefits for familiesdiscontinued from AFDC until the familys eligibility or ineligibility forMedi-Cal only has been determined and an appropriate Notice ofAction sent.

39

Full Scope

No

Initial Transitional Medi-Cal (TMC) Six Months Continuing Eligibility

(FFP). Provides coverage to certain clients subsequent to AFDC cashgrant discontinuance due to increased earnings, increased hours ofemployment or loss of the $30 and 1/3 disregard.

4A

Full Scope

No

Adoption Assistance Program (AAP). Program for AAP children for

whom there is a state-only AAP agreement between any state otherthan California and adoptive parent(s).

those children who are in need of substitute parenting and who havebeen voluntarily placed in foster care.

4D

None

No

ADAM

4E

Full Scope

No

Hospital PE Former Foster Care Up to age 26.

4F

Full Scope

No

Kinship Guardianship Assistance Payment (Kin-GAP). Federal program

for children in relative placement receiving cash assistance.

4G

Full Scope

No

Kin-GAP. State-only program for children in relative placement

receiving cash assistance.

4H

Full Scope

No

Foster Care Children in CALWORKS.

4K

Full Scope

No

Emergency Assistance (EA) Program (FFP). Covers juvenile probation

cases placed in foster care.

4L

Full Scope

No

Foster Care Children In 1931(B)

4M

Full Scope

No

Former Foster Care Children (FFCC) 18 through 20 years of age.

Provides Full Scope Medi-Cal benefits to former foster care childrenwho were receiving benefits on their 18th birthday in Aid Codes 40, 42,45, 4C and 5K and who are under 21 years of age.

Third Quarter, 2016

Treating BeneficiariesPage 4-33

AidCode

SOC

Program/Description

4N

Full Scope

Benefits

No

Covers NMD, age 18 but under age 21, under AB 12 on whose behalffinancial assistance is provided for foster care placement, living with anapproved CalWORKs relative who is not eligible for Kin-GAP or fostercare

4P

None

No

CalWORKs Family Reunification ALL FAMILIES, provides for the

continuance of CalWORKs services to all families except two parentfamilies, under certain circumstances, when a child has been removedfrom the home and is receiving out-of-home care.

4R

None

No

CalWORKs FAMILY REUNIFICATION TWO PARENT, provides for the

continuation of CalWORKs services to two-parent families, undercertain circumstances, when a child has been removed from the homeand is receiving out-of-home care.

4S

Full Scope

No

Serves former foster care NMDs over age 18, but under age 21, bymoving them from foster care placements to more permanentplacement options through the establishment of a relative guardianshipthat occurred on or after age 16. (Also includes youth age 18 but underage 21 based on a disability.)

4T

Full Scope

No

IV-E KinGAP Full Scope No SOC to 21 years-old with exceptions

4U

Ful Scope

No

FFCC Optional Coverage Group

4V

Full Scope

Yes

TVCAP RMA Medi-CAL SOC

4W

Full Scope

No

Covers NMDs age 18 but under age 21, eligible for extended KinGAPassistance based on a disability or based on the establishment of theguardianship that occurred on or after age 16. Non-Title IV-E KinGAPmust have a full Medicaid eligibility determination.

40

Full Scope

No

AFDC-FC/Non-Fed (State FC). Provides financial assistance for those

children who are in need of substitute parenting and who have beenplaced in foster care.

41

None

No

AFDC - FOSTER CARE - SERVICES ONLY

42

Full Scope

No

AFDC-FC/Fed (FFP). Provides financial assistance for those children who

are in need of substitute parenting and who have been placed in fostercare.

43

Full Scope

No

Covers NMD, age 18 but under age 21, under AB 12 on whose behalffinancial assistance is provided for state-only foster care placement.

44

Restricted topregnancy-relatedservices

No

Income Disregard Program. Pregnant (FFP) United States Citizen/U.S.

National and aliens with satisfactory immigration status including lawfulPermanent Resident Aliens/Amnesty Aliens and PRUCOL Aliens.Provides family planning, pregnancy-related and postpartum servicesfor any female if family income is at or below 200 percent of the federalpoverty level.

45

Full Scope

No

Children Supported by Public Funds (FFP). Children whose needs are

met in whole or in part by public funds other than AFDC-FC.

Treating BeneficiariesPage 4-34

Formatted: Strong, Font: Not Bold

Third Quarter, 2016

AidCode

Benefits

SOC

Program/Description

47

Full Scope

No

Income Disregard Program (FFP). Infant United States Citizen,

Permanent Resident Alien/PRUCOL Alien. Provides full Medi-Calbenefits to infants up to 1 year old and continues beyond 1 year wheninpatient status, which began before first birthday, continues andfamily income is at or below 200 percent of the federal poverty level.

48

Restricted topregnancy-relatedservices

No

Income Disregard Program. Pregnant Covers aliens who do not have

lawful permanent resident, PRUCOL, or amnesty status (includingundocumented aliens), but who are otherwise eligible for Medi-Cal.Provides family planning, pregnancy-related and postpartum servicesfor any age female if family income is at or below 200 percent of thefederal poverty level. Routine prenatal care is non-FFP. Labor, deliveryand emergency prenatal care are FFP.

49

Full Scope

No

Covers NMD, age 18 but under age 21, under AB 12 on whose behalffinancial assistance is provided for federal foster care placement.

5A

None

5C

Full Scope

No

HFP to Medi-Cal Transitional PE-No Premium

5D

Full Scope

No

HFP to Medi-Cal Transitional PE-Premium Payment

5E

Full Scope

No

HF to Medi-Cal PE-No SOC

5F

Restricted to pregnancyand emergency services

Y/N

OBRA Aliens. Covers pregnant alien women who do not have lawfulpermanent resident, PRUCOL or amnesty status (includingundocumented aliens), but who are otherwise eligible for Medi-Cal.

Four Month Continuing (FFP). Provides four months of emergency and

pregnancy-related benefits (no SOC) for aliens without SIS who are nolonger eligible for Section 1931(b) due to the collection or increasedcollection of child/spousal support.

5X

Full Scope

No

Second Year Transitional Medi-Cal (TMC). Provides a second year of Full

Scope (no SOC) TMC benefits for citizens and qualified aliens age 19 andolder who have received six months of additional Full Scope TMCbenefits under aid code 59 and who continue to meet the requirementsof additional TMC. (State-only program.)

Third Quarter, 2016

EA Seriously Emotionally Disturbed

Treating BeneficiariesPage 4-35

AidCode

Benefits

SOC

Program/Description

50

Restricted to CMSPemergency servicesonly

Y/N

CMSP is administered by Doral Dental Services of California:

(800) 341-8478.

51

Full Scope

Yes

IRCA ALIENS - FULL SCOPE BENEFITS

52

Limited Scope

Yes

IRCA ALIENS - EMERGENCY BENEFITS

53

Restricted to LTCservices only

Y/N

Medically Indigent LTC (Non-FFP). Covers persons age 21 or older and

under 65 years of age who are residing in a Nursing Facility Level A or Band meet all other eligibility requirements of medically indigent, with orwithout SOC.

54

Full Scope

No

Four-Month Continuing Eligibility (FFP). Covers persons discontinued

from AFDC due to the increased collection of child/spousal supportpayments but eligible for Medi-Cal only.

55

Restricted to pregnancyand emergency services

No

Aid to Undocumented Aliens in LTC Not PRUCOL. Covers undocumented

aliens in LTC not Permanently Residing Under Color Of Law (PRUCOL).LTC services: State-only funds; emergency and pregnancy-relatedservices: State and federal funds. Recipients will remain in this aid codeeven if they leave LTC.

56

Full Scope

57

IRCA AG WKRS - FULL SCOPE BENEFITS

Limited Scope

Yes

IRCA AG WKRS - EMERGENCY BENEFITS

58

Restricted to pregnancyand emergency services

Y/N

OBRA Aliens. Covers aliens who do not have lawful permanent resident,PRUCOL or amnesty status (including undocumented aliens), but whoare otherwise eligible for Medi-Cal.

59

Full Scope

No

Additional TMC Additional Six Months Continuing Eligibility (FFP).

Covers persons discontinued from AFDC due to the expiration of the$30 plus 1/3 disregard, increased earnings or hours of employment, buteligible for Medi-Cal only, may receive this extension of TMC.

6A

Full Scope

No

Disabled Adult Child(ren) (DAC)/Blindness (FFP).

6C

Full Scope

No

Disabled Adult Child(ren) (DAC)/Disabled (FFP).

6D

Full Scope

Y/N

Disabled In-Home Support Services (IHSS). Covers disabled individuals

discontinued from the IHSS residual program for reasons other than theloss of Supplemental Security Income/State Supplemental Payment(SSI/SSP) until the county determines their Medi-Cal eligibility.

6E

Full Scope

No

Craig v Bonta Continued Eligibility for the Disabled. Aid code 6E coversformer SSI beneficiaries who are disabled (with the exception ofpersons who are deceased or incarcerated in a correctional facility)until the county redetermines their Medi-Cal eligibility. Provides feefor-service full scope Medi-Cal without a share of cost and with federalfinancial participation.

6F

None

Yes

PERSONAL CARE SERVICES PROGRAM

Treating BeneficiariesPage 4-36

Third Quarter, 2016

AidCode

Benefits

SOC

Program/Description

6G

Full Scope

No

250 Percent Program Working Disabled. Provides Full Scope Medi-Cal

benefits to working disabled recipients who meet the requirements ofthe 250 Percent Program.

6H

Full Scope

No

Federal Poverty Level Disabled (FPL-Disabled) Provides Full Scope (no

Share of Cost benefits to recipients 21 to 65 years of age, who have losttheir non-disability linkage to Medi-Cal and the client claims disability.Medi-Cal coverage continues uninterrupted during the determinationperiod.

6K

None

CAPI Non-Qualified Aliens

6M

None

CAPI Sponsored Aliens

6N

Full Scope

No

Personal Responsibility and Work Opportunity Reconciliation Act

(PRWORA)/No Longer Disabled Recipients (FFP). Former SSI disabledrecipients (adults and children not in aid code 6R) who are appealingtheir cessation of SSI disability.

6P

Full Scope

No

PRWORA/No Longer Disabled Children (FFP). Covers children under age

18 who lost SSI cash benefits on or after July 1, 1997, due to PRWORAof 1996, which provides a stricter definition of disability for children.

6R

Full Scope

Yes

Senate Bill (SB) 87 Pending Disability Program. Provides Full Scope,

Share of Cost benefits to recipients 21 to 65 years of age, who have losttheir non-disability linkage to Medi-Cal and the client claims disability.Medi-Cal coverage continues uninterrupted during the determinationperiod.

6S

Full Scope

No

State Only This aid code supplants those that were in Aid Code 65prior to 8/24/05 - Aid to the Disabled Substantial Gainful Activity/Aged,Blind, Disabled Medically Needy IHSS (non-FFP). Covers persons who(a) were once determined to be disabled in accordance with theprovisions of the SSI/SSP program and were eligible for SSI/SSP butbecame ineligible because of engagement in substantial gainful activityas defined in Title XVI regulations. They must also continue to sufferfrom the physical or mental impairment that was the basis of thedisability determination or (b) are aged, blind, or disabled medicallyneedy, and have the costs of IHSS deducted from their monthly income.

6T

None

6U

Restricted to pregnancyand emergency services

No

Restricted Federal Poverty Level Disabled (Restricted FPL-Disabled)

Provides emergency and pregnancy-related benefits (no Share of Cost)to qualified disabled individuals/couples who do not have satisfactoryimmigration status.

Aid to the Disabled IHSS (FFP). Covers persons who meet the federaldefinition of disability and are eligible for IHSS. (See Aid Codes 18 and65 for definition of eligibility for IHSS).

7A

Full Scope

No

100 Percent Program. Child (FFP) United States Citizen, Lawful

Permanent Resident/PRUCOL/(IRCA Amnesty Alien [ABD or Under 18]).Provides full benefits to otherwise eligible children, ages 6 to 19 andbeyond 19 when inpatient status began before the 19th birthday andfamily income is at or below 100 percent of the Federal poverty level.

7C

Restricted to pregnancyand emergency services

No

100 Percent Program. Child Undocumented/ Nonimmigrant

Status/[IRCA Amnesty Alien (Not ABD or Under 18)]. Covers emergencyand pregnancy-related services to otherwise eligible children, ages 6 to19 and beyond 19 when inpatient status begins before the 19thbirthday and family income is at or below 100 percent of the Federalpoverty level.

7E

Full Scope

No

100% New Entrant Non-Immigrant

Treating BeneficiariesPage 4-38

Third Quarter, 2016

AidCode

Benefits

SOC

Program/Description

7F

Valid for pregnancy

allows the Qualified Provider to make a determination of PE foroutpatient prenatal care services based on preliminary incomeinformation. 7F is valid for pregnancy test, initial visit, and servicesassociated with the initial visit. Persons placed in 7F have pregnancytest results that are negative.

7G

Valid only for

ambulatory prenatalcare services

No

Presumptive Eligibility (PE) Ambulatory Prenatal Care Services (FFP).

This option allows the Qualified Provider to make a determination of PEfor outpatient prenatal care services based on preliminary incomeinformation. 7G is valid for Ambulatory Prenatal Care Services. Personsplaced in 7G have pregnancy test results that are positive.

HF to adults and children who at the annual review are ineligible for HFand appear to qualify for Medi-Cal.

71

Restricted to dialysisand supplementaldialysis-related services

Y/N

Medi-Cal Dialysis Only Program/Medi-Cal Dialysis Supplement Program

(DP/DSP) (Non-FFP). Covers persons of any age who are eligible only fordialysis and related services.

72

Full Scope

No

133 Percent Program. Child-United States Citizen, Permanent Resident

Alien/PRUCOL Alien (FFP). Provides full Medi-Cal benefits to childrenages 1 up to 6 and beyond 6 years when inpatient status, which beganbefore sixth birthday, continues, and family income is at or below 133percent of the federal poverty level.

73

Restricted to parenteralhyperalimentationrelated expenses

Y/N

Medi-Cal TPN Only Program/Medi-Cal TPN Supplement Program (NonFFP). Covers persons of any age who are eligible for parenteralhyperalimentation and related services and persons of any age who areeligible under the Medically Needy or Medically Indigent Programs.

74

Restricted toemergency services

No

133 Percent Program (OBRA). Child Undocumented/ Nonimmigrant

Alien (but otherwise eligible) (FFP). Provides emergency services onlyfor children ages 1 up to 6 and beyond 6 years when inpatient status,which began before sixth birthday, continues, and family income is at orbelow 133 percent of the federal poverty level.

76

Restricted to 60-daypostpartum services

No

60-Day Postpartum Program. Provides Medi-Cal at no SOC to women

who, while pregnant, were eligible for, applied for, and received MediCal benefits. They may continue to be eligible for all postpartumservices and family planning. This coverage begins on the last day ofpregnancy and ends the last day of the month in which the 60th dayoccurs.

79

Full Scope

No

Asset Waiver Program (Infant). Provides full Medi Cal benefits to infantsup to 1 year, and beyond 1 year when inpatient status, which beganbefore first birthday, continues and family income is between 185percent and 200 percent of the federal poverty level (State-OnlyProgram).

8A

None

No

QUALIFIED DISABLED WORKING INDIVIDUAL (QDWI)

8C

None

No

SPECIFIED LOW INCOME MEDI-CAL BENEFICIARY (SLMB)

8D

None

No

QUALIFYING INDIVIDUAL - 1 PROGRAM (QI-1)

8E

Full Scope

No

Children under the age of 19, apparently eligible for any no-cost MediCal program, will receive immediate, temporary, fee-for-service, FullScope, no-cost Medi-Cal benefits.

Treating BeneficiariesPage 4-40

Third Quarter, 2016

AidCode

Benefits

SOC

Program/Description

8F

CMSP services only

(companion aid code)

Y/N

CMSP is administered by Doral Dental Services of California:

(800) 341-8478.

8G

Full Scope

No

Qualified Severely Impaired Working Individual Program Aid Code.

Allows recipients of the Qualified Severely Impaired Working IndividualProgram to continue their Medi-Cal eligibility.

8H

Family PACT (SOFP

services only). No MediCal

N/A

Family PACT (also known as SOFP State Only Family Planning).

Comprehensive family planning services for low income residents ofCalifornia with no other source of health care coverage.

8K

None

No

QUALIFYING INDIVIDUAL - 2 PROGRAM (QI-2)

8N

Restricted toemergency services

No

133 Percent Program (OBRA). Child Undocumented/ Nonimmigrant

Alien (but otherwise eligible except for excess property) (FFP). Providesemergency services only for children ages 1 up to 6 and beyond 6 yearswhen inpatient status, which began before sixth birthday, continues,and family income is at or below 133 percent of the federal povertylevel.

8P

Full Scope

No

133 Percent Program. Child United States Citizen (with excess

property), Permanent Resident Alien/PRUCOL Alien (FFP). Provides FullScope Medi-Cal benefits to children ages 1 up to 6 and beyond 6 yearswhen inpatient status, which began before sixth birthday, continues,and family income is at or below 133 percent of the federal povertylevel.

8R

Full Scope

No

100 Percent Program. Child (FFP) United States Citizen (with excessproperty), Lawful Permanent Resident/ PRUCOL/(IRCA Amnesty Alien[ABD or Under 18]). Provides Full Scope benefits to otherwise eligiblechildren, ages 6 to 19 and beyond 19 when inpatient status beginsbefore the 19th birthday and family income is at or below 100 percentof the federal poverty level.

8T

Restricted to pregnancyand emergency services

No

100 Percent Program. Child Undocumented/Nonimmigrant

Status/(IRCA Amnesty Alien [with excess property]). Covers emergencyand pregnancy-related services only to otherwise eligible children ages6 to 19 and beyond 19 when inpatient status begins before the 19thbirthday and family income is at or below 100 percent of the federalpoverty level.

8U

Full Scope

No

Deemed Eligibility (DE) CHDP Gateway/Medi-Cal. Provides Full Scope no

Share of Cost (SOC) Medi-Cal benefits for infants born to mothers whowere enrolled in Medi-Cal with no SOC in the month of the infantsbirth.

8V

Full Scope

Yes

Deemed Eligibility (DE) CHDP Gateway/Medi-Cal. Provides Full Scope

Medi-Cal benefits with a Share of Cost (SOC) for infants born tomothers who were enrolled in Medi-Cal with a SOC in the month of theinfants birth and SOC was met.

Third Quarter, 2016

Treating BeneficiariesPage 4-41

AidCode

SOC

Program/Description

8W

Full Scope

Benefits

No

Child Health Disability Program (CHDP) Gateway Medi-Cal Aid Code

8W provides for the pre-enrollment of children into the Medi-Calprogram which will provide temporary, no share of cost (SOC), FullScope Denti-Cal benefits. Federal Financial Participation (FFP) for thesebenefits is available through Title XIX of the Social Security Act.

8X

Full Scope

No

CHDP Gateway Healthy Families Aid Code 8X provides pre-enrollment

of children into the Medi-Cal program. Provides temporary, Full ScopeDenti-Cal benefits with no SOC until eligibility for the Healthy Familiesprogram can be determined. Federal Financial Participation (FFP) forthese benefits is available through Title XXI of the Social Security Act.

8Y

CHDP Only

No

CHDP Aid Code 8Y provides eligibility to the CHDP ONLY program forchildren who are known to MEDS as not having satisfactory immigrationstatus. There is no Federal Financial Participation for these benefits.This aid code is state funded only.

80

Restricted to Medicareexpenses

No

Qualified Medicare Beneficiary (QMB). Provides payment of Medicare

Part A premium and Part A and B coinsurance and deductibles foreligible low income aged, blind, or disabled individuals.

81

Full Scope

Y/N

MI-Adults Aid Paid Pending (Non-FFP). Aid Paid Pending for personsover 21 but under 65, with or without SOC.

82

Full Scope

No

MI-Person (FFP). Covers medically indigent persons under 21 who meet

the eligibility requirements of medical indigence. Covers persons untilthe age of 22 who were in an institution for mental disease before age21. Persons may continue to be eligible under Aid Code 82 until age 22if they have filed for a State hearing.

83

Full Scope

Yes

MI-Person SOC (FFP). Covers medically indigent persons under 21 who

meet the eligibility requirements of medically indigent.

84

CMSP services only (no

Medi-Cal)

No

CMSP is administered by Doral Dental Services of California:

(800) 341-8478.

85

CMSP services only (no

Medi-Cal)

Yes

CMSP is administered by Doral Dental Services of California:

(800) 341-8478.

86

Full Scope

No

MI-Confirmed Pregnancy (FFP). Covers persons aged 21 years or older,

with confirmed pregnancy, who meet the eligibility requirements ofmedically indigent.

87

Full Scope

Yes

MI-Confirmed Pregnancy (FFP). Covers persons aged 21 or older, with

confirmed pregnancy, who meet the eligibility requirements ofmedically indigent but are not eligible for 185 percent/200 percent orthe MN programs.

88

CMSP services only (no

Medi-Cal)

No

CMSP is administered by Doral Dental Services of California:

(800) 341-8478.

89

CMSP services only (no

Medi-Cal)

Yes

CMSP is administered by Doral Dental Services of California:

(800) 341-8478.

Treating BeneficiariesPage 4-42

Third Quarter, 2016

AidCode9A

BenefitsBCEDP only

SOC

Program/Description

No

The Breast Cancer Early Detection Program (BCEDP) recipient identifier.

EXPANDED ACCESS TO PRIMARY CARE

9D

No Dental

No

CCS Only Child Enrolled in a Health Care Plan

9G

None

9H

HF services only (no

Medi-Cal)

N/A

The Healthy Families (HF) Program provides a comprehensive health

insurance plan for uninsured children from 1 to 19 years of age whosefamilys income is at or below 250 percent of the federal poverty level.HF covers medical, dental and vision services to enrolled children.

Eligible for CCS Medical Therapy Program services only.

CCS Case Management

CCS-eligible Healthy Families Child. A child in this program is enrolled in

a Healthy Families plan and is eligible for all CCS benefits (i.e., diagnosis,treatment, therapy and case management). The child's county ofresidence has no cost sharing for the child's CCS services.

9T

Full Scope

No

HF adults linked by a child who is eligible for no Share of Cost Medi-Cal

or HF.

9U

CCS

NO

CCS-eligible Healthy Families child. A child in this program is enrolled in

a Healthy Families plan and is eligible for all CCS benefits (i.e. diagnosis,treatment, therapy and case management). The child's county ofresidence has county cost sharing for the child's CCS services.

OBRA Aliens and Unverified Citizens. Covers eligible aliens who do nothave satisfactory immigration status and unverified citizens.MI - Child. Covers medically indigent persons under 21 who meet theeligibility requirements of medical indigence. Covers persons until theage of 22 who were in an institution for mental disease before age 21.Persons may continue to be eligible under aid code 82 until age 22 ifthey have filed for a State hearing.

Third Quarter, 2016

AidCodeD2

Benefits

SOC

Program/Description

Restricted to pregnancyand emergency services

No

OBRA Aliens - Not PRUCOL and Unverified Citizens - Long Term Care(LTC) services. Covers eligible undocumented aliens in LTC who are notPRUCOL and unverified citizens. Recipients will remain in this aid codeeven if they leave LTC. For more information about LTC services, referto the OBRA and IRCA section in this manual.Aid to the Aged - Long Term Care (LTC). Covers persons 65 years of ageor older who are medically needy and in LTC status.Providers Note: Long Term Care services refers to both those servicesincluded in the per diem base rate of the LTC provider, and thosemedically necessary services required as part of the patient's day-today plan of care in the LTC facility (for example, pharmacy, supportsurfaces and therapies).

D3

Restricted to pregnancyand emergency services

Yes

OBRA Aliens - Not PRUCOL and Unverified Citizens - Long Term Care(LTC) services. Covers eligible undocumented aliens in LTC who are notPRUCOL and unverified citizens. Recipients will remain in this aid codeeven if they leave LTC. For more information about LTC services, referto the OBRA and IRCA section in this manual.Aid to the Aged - Long Term Care (LTC), SOC. Covers persons 65 years ofage or older who are medically needy and in LTC status.Providers Note: Long Term Care services refers to both those servicesincluded in the per diem base rate of the LTC provider, and thosemedically necessary services required as part of the patient's day-today plan of care in the LTC facility (for example, pharmacy, supportsurfaces and therapies).

D4

Restricted to pregnancyand emergency services

No

OBRA Aliens - Not PRUCOL and Unverified Citizens - Long Term Care(LTC) services. Covers eligible undocumented aliens in LTC who are notPRUCOL and unverified citizens. Recipients will remain in this aid codeeven if they leave LTC. For more information about LTC services, referto the OBRA and IRCA section in this manual.Blind - Long Term Care (LTC).Providers Note: Long Term Care services refers to both those servicesincluded in the per diem base rate of the LTC provider, and thosemedically necessary services required as part of the patient's day-today plan of care in the LTC facility (for example, pharmacy, supportsurfaces and therapies).

Third Quarter, 2016

Treating BeneficiariesPage 4-45

AidCodeD5

Benefits

SOC

Program/Description

Restricted to pregnancyand emergency services

Yes

OBRA Aliens - Not PRUCOL and Unverified Citizens - Long Term Care(LTC) services. Covers eligible undocumented aliens in LTC who are notPRUCOL and unverified citizens. Recipients will remain in this aid codeeven if they leave LTC. For more information about LTC services, referto the OBRA and IRCA section in this manual.Blind - Long Term Care (LTC), SOC.Providers Note: Long Term Care services refers to both those servicesincluded in the per diem base rate of the LTC provider, and thosemedically necessary services required as part of the patient's day-today plan of care in the LTC facility (for example, pharmacy, supportsurfaces and therapies).

D6

Restricted to pregnancyand emergency services

No

OBRA Aliens - Not PRUCOL and Unverified Citizens - Long Term Care(LTC) services. Covers eligible undocumented aliens in LTC who are notPRUCOL and unverified citizens. Recipients will remain in this aid codeeven if they leave LTC. For more information about LTC services, referto the OBRA and IRCA section in this manual.Disabled - Long Term Care (LTC).Providers Note: Long Term Care services refers to both those servicesincluded in the per diem base rate of the LTC provider, and thosemedically necessary services required as part of the patient's day-today plan of care in the LTC facility (for example, pharmacy, supportsurfaces and therapies).

D7

Restricted to pregnancyand emergency services

Yes

OBRA Aliens - Not PRUCOL and Unverified Citizens - Long Term Care(LTC) services. Covers eligible undocumented aliens in LTC who are notPRUCOL and unverified citizens. Recipients will remain in this aid codeeven if they leave LTC. For more information about LTC services, referto the OBRA and IRCA section in this manual.Disabled - Long Term Care (LTC), SOC.Providers Note: Long Term Care services refers to both those servicesincluded in the per diem base rate of the LTC provider, and thosemedically necessary services required as part of the patient's day-today plan of care in the LTC facility (for example, pharmacy, supportsurfaces and therapies).

Effective June 1, 2014

Manual of CriteriaPage 5-1

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Manual of CriteriaPage 5-2

Effective June 1, 2014

Current Dental Terminology 13 (CDT 13) Codes Preface

Current Dental Terminology 13 (CDT 13) including procedure codes, definitions (descriptors) and other data iscopyrighted by the American Dental Association. 2012 American Dental Association. All rights reserved.Applicable FARS/DFARS apply.IMPORTANT: Effective July 1, 2009, Assembly Bill X3 5 (Evans, Chapter 20, Statutes of 2009-10) added Section14131.10 to the Welfare and Institutions Code, which eliminated specific optional benefits from the Medi-Calprogram, including most dental services for adults ages 21 and older. Effective May 1, 2014 some adult dentalbenefits have been restored in accordance with Assembly Bill 82 (AB 82). Unless specifically identified in theAssembly Bill as a change, the criteria contained in this next section, the Manual of Criteria for Medi-CalAuthorization (Dental Services) will remain in effect. Refer to Section 4: Elimination of Optional Adult DentalServices to view the list of Table 1: Federally Required Adult Dental Services (FRADS) and Table 3: RestoredAdult Dental Services (RADS) for the exemptions that apply.

Effective June 1, 2014

Manual of CriteriaPage 5-3

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Manual of CriteriaPage 5-4

Effective June 1, 2014

Diagnostic General Policies (D0100-D0999)

CDT-4 Codes

Diagnostic General Policies (D0100-D0999)

1.

2.

3.

Radiographs (D0210-D0340):A) According to accepted standards of dental practice, the lowest number of radiographs needed to providethe diagnosis shall be taken.B) Original radiographs shall be a part of the patients clinical record and shall be retained by the provider atall times.C) Radiographs shall be made available for review upon the request of the Department of Health Services orits fiscal intermediary.D) Pursuant to Title 22, CCR, Section 51051, dental radiographic laboratories shall not be consideredproviders under the Medi-Cal Dental Program.E) Radiographs shall be considered current as follows:i) radiographs for treatment of primary teeth within the last eight months.ii) radiographs for treatment of permanent teeth (as well as over-retained primary teeth where thepermanent tooth is congenitally missing or impacted) within the last 14 months.iii) radiographs to establish arch integrity within the last 36 months. Arch radiographs are not requiredfor patients under the age of 21.F) All radiographs or paper copies of radiographs shall be of diagnostic quality, properly mounted, labeledwith the date the radiograph was taken, the providers name, the providers billing number, the patientsname, and with the tooth/quadrant/area (as applicable) clearly indicated.G) Multiple radiographs of four or more shall be mounted. Three or fewer radiographs properly identified (asstated in e above) in a coin envelope are acceptable when submitted for prior authorization and/orpayment.H) Paper copies of multiple radiographs shall be combined on no more than four sheets of paper.I) All treatment and post treatment radiographs are included in the fee for the associated procedure andare not payable separately.J) A panoramic radiograph alone is considered non-diagnostic for prior authorization and/or payment ofrestorative, endodontic, periodontic, removable partial and fixed prosthodontic procedures.K) When arch integrity radiographic images are required for a procedure and exposure to radiation shouldbe minimized due to a medical condition, only a periapical radiograph shall be required. Submittedwritten documentation shall include a statement of the medical condition such as the following:i) pregnancy,ii) recent application of therapeutic doses of ionizing radiation to the head and neck areas,iii) hypoplastic or aplastic anemia.L) Prior authorization for procedures other than fixed partial dentures, removable prosthetics and implantsis not required when a patients inability to respond to commands or directions would necessitatesedation or anesthesia in order to accomplish radiographic procedures. However, required radiographsshall be obtained during treatment and shall be submitted for consideration for payment.Photographs (D0350):A) Photographs are a part of the patients clinical record and the provider shall retain original photographs atall times.B) Photographs shall be made available for review upon the request of the Department of Health CareServices or its fiscal intermediary.Prior authorization is not required for examinations, radiographs or photographs.

Effective June 1, 2014

Manual of CriteriaPage 5-5

Diagnostic General Policies (D0100-D0999)

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Manual of CriteriaPage 5-6

Effective June 1, 2014

Diagnostic Procedures (D0100-D0999)

Diagnostic Procedures (D0100-D0999)

PROCEDURE D0120

PROCEDURE D0140

PERIODIC ORAL EVALUATION ESTABLISHED PATIENT

LIMITED ORAL EVALUATION PROBLEM FOCUSED

1.

1.

2.

3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. for patients under theage of 21.b. once every six months,per provider, orc. after six months haveelapsed followingcomprehensive oralevaluation (D0150), sameprovider.This procedure is not abenefit when provided on thesame date of service withprocedures:a. limited oral evaluationproblem focused(D0140),b. comprehensive oralevaluation- new orestablished patient(D0150),c. Detailed and extensiveoral evaluation-problemfocused, by report(D0160),d. re-evaluation- limited,problem focused(established patient; notpost-operative visit)(D0170),e. office visit forobservation (duringregularly scheduledhours)-no other servicesperformed (D9430).

Effective June 1, 2014

2.

3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. for patients under theage of 21.b. once per patient perprovider.c. when provided by aMedi-Cal Dental Programcertified orthodontist.Submission of theHandicapping Labio-LingualDeviation (HLD) IndexCalifornia Modification ScoreSheet Form, DC016 (06/09) isnot required for payment.The following procedures arenot a benefit, for the samerendering provider, whenprovided on the same date ofservice with procedureD0140:a. periodic oral evaluation(D0120),b. comprehensive oralevaluation- new orestablished patient(D0150),c. Detailed and extensiveoral evaluation- problemfocused, by report(D0160),d. re-evaluation-limited,problem focused(established patient; notpost- operative visit)(D0170),

PROCEDURE D0145ORAL EVALUATION FOR APATIENT UNDER THREE YEARS OFAGE AND COUNSELING WITHPRIMARY CAREGIVERThis procedure can only bebilled as periodic oralevaluation-establishedpatient (D0120) orcomprehensive oralevaluation-new or establishedpatient (D0150)-and is notpayable separately.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once per patient perprovider for the initialevaluation.This procedure is not abenefit when provided on thesame date of service withprocedures:Manual of CriteriaPage 5-7

Written documentation for

payment- shall include anevaluation and diagnosisjustifying the medicalnecessity.A benefit for the ongoingsymptomatic care oftemporomandibular jointdysfunction:a. up to six times in a threemonth period.b. up to a maximum of 12 ina 12-month period.This procedure is not abenefit when provided on thesame date of service with adetailed and extensive oralevaluation (D0160).The following procedures arenot a benefit when provided

PROCEDURE D0190SCREENING OF A PATIENTThis procedure is not abenefit.

PROCEDURE D0191ASSESSMENT OF A PATIENTThis procedure is not abenefit.

PROCEDURE D0210INTRAORAL - COMPLETE SERIESOF RADIOGRAPHIC IMAGES1.

2.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once per providerevery 36 months.Effective June 1, 2014

Diagnostic Procedures (D0100-D0999)

3.

4.

5.

Not a benefit to the same

provider within six months ofbitewings (D0272 and D0274).A complete series shall be atleast:a. ten (10) periapicals(D0230) and bitewings(D0272 or D0274), orb. eight (8) periapicals(D0230), two (2) occlusals(D0240) and bitewings(D0272 or D0274), orc. a panoramic radiographicimage (D0330) plusbitewings (D0272 orD0274) and a minimumof two (2) periapicals(D0230).When multiple radiographsare taken on the same date ofservice, or if an intraoralcomplete series ofradiographic images (D0210)has been paid in the last 36months, the maximumpayment shall not exceed thetotal fee allowed for anintraoral complete series.

3.

4.

1.

2.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit to a maximum of 20periapicals in a 12- monthperiod by the same provider,in any combination of thefollowing: intraoral-periapicalfirst radiographic image(D0220) and intraoralperiapical each additionalradiographic image (D0230).Periapicals taken as part of an

intraoral-complete series ofradiographic images (D0210)are not considered againstthe maximum of 20periapicals in a 12-monthperiod.This procedure is payableonce per provider per date ofservice. All additionalperiapicals shall be billed asintraoral-periapical eachadditional radiographic image(D0230).Periapicals taken inconjunction with bitewings,occlusal or panoramicradiographs shall be billed asintraoral-periapical eachadditional radiographic image(D0230).

2.

3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit to a maximum of 20periapicals in a 12- monthperiod to the same provider,in any combination of thefollowing: intraoral-periapicalfirst radiographic image(D0220) and intraoralperiapical each additionalradiographic image (D0230).Periapicals taken as part of anintraoral complete series ofradiographic images (D0210)are not considered againstthe maximum of 20 periapicalfilms in a 12 month period.Periapicals taken inconjunction with bitewings,

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit up to a maximum oftwo in a six-month period perprovider.If any radiographic image sizeother than 2 1/4" x 3" (57mmx 76mm) is used for anintraoral- occlusalradiographic image (D0240), itshall be billed as a intraoralperiapical first radiographicimage (D0220) or intraoralperiapical each additionalradiographic image (D0230)as applicable.

PROCEDURE D0250EXTRAORAL - FIRSTRADIOGRAPHIC IMAGE1.

2.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once per date ofservice.

PROCEDURE D0260EXTRAORAL - EACH ADDITIONALRADIOGRAPHIC IMAGE1.

Submission of radiographs,photographs or writtendocumentationManual of CriteriaPage 5-9

Diagnostic Procedures (D0100-D0999)

2.

demonstrating medicalnecessity is not required forpayment.A benefit up to a maximum offour on the same date ofservice.

PROCEDURE D0274

PROCEDURE D0310

BITEWINGS - FOURRADIOGRAPHIC IMAGES

SIALOGRAPHY

1.

PROCEDURE D0270BITEWING - SINGLERADIOGRAPHIC IMAGE1.

2.3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once per date ofservice.Not a benefit for a totallyedentulous area.

PROCEDURE D0272BITEWINGS - TWORADIOGRAPHIC IMAGES1.

2.3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once every sixmonths per provider.Not a benefit:a. within six months ofintraoral-complete seriesof radiographic images(D0210), same provider.b. for a totally edentulousarea.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once every sixmonths per provider.Not a benefit:a. within six months ofintraoral-complete seriesof radiographic images(D0210), same provider.b. for patients under theage of 10c. for a totally edentulousarea.

2.3.4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:for the survey of trauma orpathology.for a maximum of three perdate of service.

Submit radiology report or

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. for the survey of traumaor pathology.b. for a maximum of threeper date of service.

Written documentation for

payment-shall include theradiographic findings anddiagnosis to justify themedical necessity.The tomographic survey shallbe submitted for payment.A benefit twice in a 12-monthperiod per provider.This procedure shall includethree radiographic views ofthe right side and threeradiographic views of the leftside representing the rest,open and closed positions.

Effective June 1, 2014

Diagnostic Procedures (D0100-D0999)

PROCEDURE D0330PANORAMIC RADIOGRAPHICIMAGE1.

2.

3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once in a 36-monthperiod per provider, exceptwhen documented asessential for a follow-up/postoperative exam (such as afteroral surgery).Not a benefit, for the sameprovider, on the same date ofservice as an intraoralcomplete series ofradiographic images (D0210).This procedure shall beconsidered part of anintraoral- complete series ofradiographic images (D0210)when taken on the same dateof service with bitewings(D0272 or D0274) and aminimum of two (2) intraoralperiapicals each additionalradiographic image (D0230).

PROCEDURE D0340CEPHALOMETRIC RADIOGRAPHICIMAGE1.

2.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit twice in a 12-monthperiod per provider.

PROCEDURE D0350ORAL/FACIAL PHOTOGRAPHICIMAGES1.

2.3.

4.

5.

6.

Treatment AuthorizationRequest (TAR) for theprocedure that it supports,for payment.A benefit up to a maximum offour per date of service.Not a benefit when used forpatient identification,multiple views of the samearea, treatment progress andpost-operative photographs.Photographs shall benecessary for the diagnosisand treatment of the specificclinical condition of thepatient that is not readilyapparent on radiographs.Photographs shall be ofdiagnostic quality, labeledwith the date the photographwas taken, the providersname, the providers billingnumber, the patients nameand with thetooth/quadrant/area (asapplicable) clearly indicated.This procedure is included inthe fee for pre-orthodontictreatment visit (D8660) andcomprehensive orthodontictreatment of the adolescentdentition (D8080) and is notpayable separately.

Diagnostic Procedures (D0100-D0999)

3.

4.

original casts, as casts will not

be returned.A benefit:a. once per provider unlessspecial circumstances aredocumented (such astrauma or pathologywhich has affected thecourse of orthodontictreatment).b. for patients under theage of 21.c. for permanent dentition(unless over the age of 13with primary teeth stillpresent or has a cleftpalate or craniofacialanomaly).d. only when provided by aMedi-Cal Dental Programcertified orthodontist.Diagnostic casts shall be freeof voids and be properlytrimmed with centricocclusion clearly marked onthe casts. Casts shall becleaned, treated with anapproved EPA disinfectantand dried before being placedin a sealed bag for shipping tothe Medi-Cal Dental Program.

PROCEDURE D0472ACCESSION OF TISSUE, GROSSEXAMINATION, PREPARATIONAND TRANSMISSION OF WRITTENREPORTThis procedure is not abenefit.

PROCEDURE D0473

PROCEDURE D0474

PROCEDURE D0480

ACCESSION OF TISSUE, GROSS

AND MICROSCOPICEXAMINATION, INCLUDINGASSESSMENT OF SURGICALMARGINS FOR PRESENCE OFDISEASE, PREPARATION ANDTRANSMISSION OF WRITTENREPORT

This procedure is not a

This procedure is not a

ACCESSION OF TISSUE, GROSS

AND MICROSCOPICEXAMINATION, PREPARATIONAND TRANSMISSION OF WRITTENREPORTThis procedure is not abenefit.Effective June 1, 2014

Manual of CriteriaPage 5-13

Diagnostic Procedures (D0100-D0999)

PROCEDURE D0486ACCESSION OF TRANSEPITHELIALCYTOLOGIC SAMPLE,MICROSCOPIC EXAMINATION,PREPARATION ANDTRANSMISSION OF WRITTENREPORTThis procedure is not abenefit.

PROCEDURE D0502OTHER ORAL PATHOLOGYPROCEDURES BY REPORT1.

2.

3.

b.

for a procedure that has a

CDT code that is not abenefit but the patienthas an exceptionalmedical condition tojustify the medicalnecessity.Documentation shallinclude the medicalcondition and the specificCDT code associated withthe treatment.

Submission of the pathology

report is required forpayment.A benefit only when providedby a Medi-Cal Dental Programcertified oral pathologist.This procedure shall be billedonly for a histopathologicalexamination.

Effective June 1, 2014

Preventive General Policies (D1000-D1999)

Preventive General Policies (D1000-D1999)

1.

Dental Prophylaxis and Fluoride Treatment (D1110-D1208):

A) Dental prophylaxis (D1110 and D1120) is defined as the preventive dental procedure of coronal scalingand polishing which includes the complete removal of calculus, soft deposits, plaque, stains andsmoothing of unattached tooth surfaces.B) Fluoride treatment (D1206 and D1208) is a benefit only for prescription strength fluoride products.C) Fluoride treatments do not include treatments that incorporate fluoride with prophylaxis paste, topicalapplication of fluoride to the prepared portion of a tooth prior to restoration and applications of aqueoussodium fluoride.D) The application of fluoride is only a benefit for caries control and is payable as a full mouth treatmentregardless of the number of teeth treated.E) Prophylaxis and fluoride procedures (D1120, D1206 and D1208) are a benefit once in a six-month periodwithout prior authorization under the age of 21.F) Prophylaxis and fluoride procedures (D1110, D1206 and D1208) are a benefit once in a 12-month periodwithout prior authorization for age 21 or older.G) Additional requests, beyond the stated frequency limitations, for prophylaxis and fluoride procedures(D1110, D1120, D1206 and D1208) shall be considered for prior authorization when documented medicalnecessity is justified due to a physical limitation and/or an oral condition that prevents daily oral hygiene.

Effective June 1, 2014

Manual of CriteriaPage 5-15

Preventive General Policies (D1000-D1999)

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Manual of CriteriaPage 5-16

Effective June 1, 2014

Preventive Procedures (D1000-D1999)

Preventive Procedures (D1000-D1999)

PROCEDURE D1110

a.

PROPHYLAXIS - ADULT1.

2.

3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once in a 12-monthperiod for patients age 21 orolder. Frequency limitationsshall apply toward prophylaxisprocedure D1120.Not a benefit whenperformed on the same dateof service with:a. gingivectomy orgingivoplasty (D4210 andD4211).b. osseous surgery (D4260and D4261).c. periodontal scaling androot planing (D4341 andD4342).Not a benefit to the sameprovider who performedperiodontal maintenance(D4910) in the same calendarquarter.

4.

2.

3.

Effective June 1, 2014

TOPICAL APPLICATION OFFLUORIDE1.

2.

TOPICAL APPLICATION OFFLUORIDE VARNISH1.

2.

PROPHYLAXIS - CHILDSubmission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once in a six-monthperiod for patients under theage of 21.Not a benefit whenperformed on the same dateof service with:

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once in a six monthperiod for patients underthe age of 21. Frequencylimitations shall applytoward topicalapplication of fluoride(D1208).b. once in a 12 monthperiod for patients age 21or older. Frequencylimitations shall applytoward topicalapplication of fluoride(D1208).Payable as a full mouthtreatment regardless of thenumber of teeth treated.

3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once in a six monthperiod for patients underthe age of 21. Frequencylimitations shall applytoward topicalapplication of fluoridevarnish (D1206).b. once in a 12 monthperiod for patients age 21or older. Frequencylimitations shall applytoward topicalapplication of fluoridevarnish (D1206).Payable as a full mouthtreatment regardless of thenumber of teeth treated.

PROCEDURE D1320TOBACCO COUNSELING FOR THECONTROL AND PREVENTION OFORAL DISEASEThis procedure is to beperformed in conjunctionwith diagnostic, preventive,and periodontal proceduresand is not payable separately.Manual of CriteriaPage 5-17

Preventive Procedures (D1000-D1999)

PROCEDURE D1330ORAL HYGIENE INSTRUCTIONSThis procedure is to be performedin conjunction with diagnostic,preventive, and periodontalprocedures and is not payableseparately.

2.3.4.

PROCEDURE D1351SEALANT - PER TOOTH1.

2.3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code andsurface code.A benefit:a. for first, second and thirdpermanent molars thatoccupy the second molarposition.b. only on the occlusalsurfaces that are free ofdecay and/orrestorations.c. for patients under theage of 21.d. once per tooth every 36months per providerregardless of surfacessealed.The original provider isresponsible for any repair orreplacement during the 36month period.

5.

6.7.

8.

1.

Submission of radiographs,photographs or writtendocumentationdemonstrating medical

necessity is not required for

payment.Requires a tooth code andsurface code.A benefit:for first, second and thirdpermanent molars thatoccupy the second molarposition.only for an active cavitatedlesion in a pit or fissure thatdoes not cross the DEJ.for patients under the age of21.once per tooth every 36months per providerregardless of surfaces sealed.The original provider isresponsible for any repair orreplacement during the 36month period.

4.5.

This procedure does not

require prior authorization.Radiographs for payment submit a diagnosticpreoperative periapical orbitewing radiograph todocument the presence of theerupting permanent toothand to verify there is enoughspace to allow the eruption ofthe permanent tooth.Written documentation forpayment - shall include theidentification of the missingprimary molar.Requires a quadrant code.A benefit:a. once per quadrant perpatient.b. for patients under theage of 18.c. only to maintain thespace for a single tooth.

Not a benefit:a. when the permanenttooth is near eruption oris missing.b. for upper and loweranterior teeth.c. for orthodonticappliances, toothguidance appliances,minor tooth movement,or activating wires.Replacement spacemaintainers shall beconsidered for payment whendocumentation identifies anunusual circumstance (such aslost or non-repairable).The fee for space maintainersincludes the band and loop.When prefabricated crowns(D2930, D2931, D2932 andD2933) are necessary forspace maintainer abutmentteeth they first shall meet theMedi-Cal Dental Programscriteria for prefabricatedcrowns and shall be billedseparately from the spacemaintainer.

PROCEDURE D1515SPACE MAINTAINER - FIXED BILATERAL1.2.

3.

This procedure does not

require prior authorization.Radiographs for payment submit a diagnosticpreoperative periapical orbitewing radiograph todocument the presence of theerupting permanent toothand to verify there is enoughspace to allow the eruption ofthe permanent tooth.Written documentation forpayment - shall include theidentification of the missingprimary molars.Effective June 1, 2014

Preventive Procedures (D1000-D1999)

4.5.

6.

7.

8.9.

Requires an arch code.

A benefit:a. once per arch when thereis a missing primarymolar in both quadrantsor when there are twomissing primary molars inthe same quadrant.b. for patients under theage of 18.Not a benefit:a. when the permanenttooth is near eruption oris missing.b. for upper and loweranterior teeth.c. for orthodonticappliances, toothguidance appliances,minor tooth movement,or activating wires.Replacement spacemaintainers shall beconsidered for payment whendocumentation identifies anunusual circumstance (such aslost or non-repairable).The fee for space maintainersincludes the band and loop.When prefabricated crowns(D2930, D2931, D2932 andD2933) are necessary forspace maintainer abutmentteeth they first shall meet theMedi-Cal Dental Programscriteria for prefabricatedcrowns and shall be billedseparately from the spacemaintainer.

PROCEDURE D1520SPACE MAINTAINER REMOVABLE - UNILATERAL1.2.

This procedure does not

require prior authorization.Radiographs for payment submit a diagnosticpreoperative periapical or

Effective June 1, 2014

3.

4.5.

6.

7.

8.

bitewing radiograph todocument the presence of theerupting permanent toothand to verify there is enoughspace to allow the eruption ofthe permanent tooth.Written documentation forpayment - shall include theidentification of the missingprimary molar.Requires a quadrant code.A benefit:a. once per quadrant perpatient.b. for patients under theage of 18.c. only to maintain thespace for a single tooth.Not a benefit:a. when the permanenttooth is near eruption oris missing.b. for upper and loweranterior teeth.c. for orthodonticappliances, toothguidance appliances,minor tooth movement,or activating wires.Replacement spacemaintainers shall beconsidered for payment whendocumentation identifies anunusual circumstance (such aslost or non-repairable).All clasps, rests andadjustments are included inthe fee for this procedure.

PROCEDURE D1525

3.

4.5.6.

7.8.9.10.11.

12.

13.

PROCEDURE D1550RECEMENTATION OF SPACEMAINTAINER

SPACE MAINTAINER REMOVABLE - BILATERAL

1.

1.

2.

2.

This procedure does not

document the presence of the

erupting permanent toothand to verify there is enoughspace to allow the eruption ofthe permanent tooth.Written documentation forpayment - shall include theidentification of the missingprimary molars.Requires an arch code.A benefit:once per arch when there is amissing primary molar in bothquadrants or when there aretwo missing primary molars inthe same quadrant.for patients under the age of18.Not a benefit:when the permanent tooth isnear eruption or is missing.for upper and lower anteriorteeth.for orthodontic appliances,tooth guidance appliances,minor tooth movement, oractivating wires.Replacement spacemaintainers shall beconsidered for payment whendocumentation identifies anunusual circumstance (such aslost or non-repairable).All clasps, rests andadjustments are included inthe fee for this procedure.

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Manual of CriteriaPage 5-19

Preventive Procedures (D1000-D1999)

3.4.

5.

Requires a quadrant code or

arch code, as applicable.A benefit:a. once per provider, perapplicable quadrant orarch.b. for patients under theage of 18.Additional requests beyondthe stated frequencylimitations shall be consideredfor payment when themedical necessity isdocumented and identifies anunusual condition (such asdisplacement due to a stickyfood item).

PROCEDURE D1555REMOVAL OF FIXED SPACEMAINTAINER1.2.

3.4.

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a quadrant code orarch code, as applicable.Not a benefit to the originalprovider who placed thespace maintainer.

Manual of CriteriaPage 5-20

Effective June 1, 2014

Restorative General Policies (D2000-D2999)

Restorative General Policies (D2000-D2999)

1.

Amalgam and Resin-Based Composite Restorations (D2140-D2394):

A) Restorative services shall be a benefit when medically necessary, when carious activity or fractures haveextended through the dentinoenamel junction (DEJ) and when the tooth demonstrates a reasonablelongevity.B) Amalgam and resin-based composite restoration procedures shall require submission of pre-operativeradiographs for payment, contingent upon the following rules:i) the first three amalgam and/or resin-based composite restorations that a patient receives in a 12month period do not require radiographs,ii) the fourth and additional amalgam and/or resin-based composite restorations that a patient receivesin a 12-month period do require radiographs. However, when a submitted claim includes the fourthamalgam and/or resin-based composite restoration in a 12-month period then all amalgam and/orresin-based composite restorations on that claim require radiographs.C) The submitted radiographs shall clearly demonstrate that the destruction of the tooth is due to suchconditions as decay, fracture, endodontic access or missing or defective restorations. Payment forrestorative procedures shall be modified or denied when the medical necessity is not evident.D) Anterior proximal restorations (amalgam/composite) submitted as a two or three surface restoration shallbe clearly demonstrated on radiographs that the tooth structure is involved to a point one-third themesialdistal width of the tooth.E) Should the submitted radiographs fail to demonstrate the medical necessity for the restoration, intraoralphotographs shall also be submitted as further documentation.F) When radiographs are medically contraindicated due to recent application of therapeutic doses ofionizing radiation to the head and neck areas, the reason for the contraindication shall be fullydocumented by the patients attending physician and submitted for payment. If this condition exists,intraoral photographs shall also be submitted to demonstrate the medical necessity for the restoration.G) When radiographs fail to demonstrate the medical necessity, providers shall also submit adjunctivedocumentation for consideration for payment such as: fiber optic transillumination photographs,DIAGNOdent readings, caries detection dye photographs, caries risk assessment data or operating roomreports.H) Restorative services provided solely to replace tooth structure lost due to attrition, abrasion, erosion orfor cosmetic purposes are not a benefit.I) Restorative services are not a benefit when the prognosis of the tooth is questionable due to nonrestorability or periodontal involvement.J) Restorations for primary teeth near exfoliation are not a benefit.K) The five valid tooth surface classifications are mesial, distal, occlusal/incisal, lingual and facial (includingbuccal and labial).L) Each separate non-connecting restoration on the same tooth for the same date of service shall besubmitted on separate Claim Service Lines (CSLs). All surfaces on a single tooth restored with the samerestorative material shall be considered connected, for payment purposes, if performed on the same dateof service.M) Payment is made for a tooth surface only once for the same date of service regardless of the number orcombination of restorative materials placed on that surface.N) Tooth and soft tissue preparation, crown lengthening, cement bases, direct and indirect pulp capping,bonding agents, lining agents, occlusal adjustments (D9951), polishing, local anesthesia and any otherassociated procedures are included in the fee for a completed restorative service.O) The original provider is responsible for any replacement restorations necessary in primary teeth withinthe first 12 months and permanent teeth within the first 36 months, except when failure or breakage

Effective June 1, 2014

Manual of CriteriaPage 5-21

Restorative General Policies (D2000-D2999)

2.

results from circumstances beyond the control of the provider (such as due to a patients oral habits).Radiographs (and photographs, as applicable) shall be submitted to demonstrate the need forreplacement.P) Replacement of otherwise satisfactory amalgam restorations with resin-based composite restorations isnot a benefit unless a specific allergy has been documented by a medical specialist (allergist) on theirprofessional letterhead or prescription and submitted for payment.Prefabricated Crowns (D2929-D2933):A) Primary Teeth:i) Prefabricated crowns (D2929, D2930, D2932 and D2933) are a benefit only once in a 12-monthperiod.ii) Primary teeth do not require prior authorization. Pre-operative radiographs shall be submitted forpayment. At least one of the following criteria shall be met for payment:a. Decay, fracture or other damage involving three or more tooth surfaces,b. Decay, fracture or other damage involving one interproximal surface when the damage hasextended extensively buccolingually or mesiodistally,c. the prefabricated crown is submitted for payment in conjunction with therapeutic pulpotomy orpulpal therapy (D3220, D3230 and D3240) or the tooth has had previous pulpal treatment.iii) Prefabricated crowns for primary teeth near exfoliation are not a benefit.iv) When prefabricated crowns are utilized to restore space maintainer abutment teeth they shall meetMedi-Cal Dental Program criteria for prefabricated crowns and shall be submitted separately forpayment from the space maintainer.B) Permanent Teeth:i) Prefabricated crowns (D2931, D2932 and D2933) are a benefit only once in a 36-month period.ii) Permanent teeth do not require prior authorization. Pre-operative periapical and arch radiographsshall be submitted for payment. At least one of the following criteria shall be met for payment:a. anterior teeth shall show traumatic or pathological destruction of the crown of the tooth whichinvolves four or more tooth surfaces including at least the loss of one incisal angle,b. bicuspids (premolars) shall show traumatic or pathological destruction of the crown of the toothwhich involves three or more tooth surfaces including at least one cusp,c. molars shall show traumatic or pathological destruction of the crown of the tooth which involvesfour or more tooth surfaces including at least two cusps,d. the prefabricated crown shall restore an endodontically treated bicuspid or molar tooth.iii) Arch integrity and the overall condition of the mouth, including the patients ability to maintain oralhealth, shall be considered based upon a supportable 36-month prognosis for the permanent toothto be crowned.iv) Indirectly fabricated or prefabricated posts (D2952 and D2954) are benefits when medicallynecessary for the retention of prefabricated crowns on root canal treated permanent teeth.v) Prefabricated crowns on root canal treated teeth shall be considered for payment only aftersatisfactory completion of root canal therapy. Post root canal treatment radiographs shall besubmitted for prior authorization.vi) Prefabricated crowns are not a benefit for abutment teeth for cast metal framework partial dentures(D5213 and D5214).C) Primary and Permanent Teeth:i) Prefabricated crowns provided solely to replace tooth structure lost due to attrition, abrasion,erosion or for cosmetic purposes are not a benefit.ii) Prefabricated crowns are not a benefit when the prognosis of the tooth is questionable due to nonrestorability or periodontal involvement.

Manual of CriteriaPage 5-22

Effective June 1, 2014

Restorative General Policies (D2000-D2999)

3.

iii) Prefabricated crowns are not a benefit when a tooth can be restored with an amalgam or resin-basedcomposite restoration.iv) Tooth and soft tissue preparation, crown lengthening, cement bases, direct and indirect pulp capping,amalgam or acrylic buildups, pins (D2951), bonding agents, occlusal adjustments (D9951), localanesthesia (D9210) and any other associated procedures are included in the fee for a prefabricatedcrown.v) The original provider is responsible for any replacement prefabricated crowns necessary in primaryteeth within the first 12 months and permanent teeth within the first 36 months, except when failureor breakage results from circumstances beyond the control of the provider (such as due to a patientsoral habits).Laboratory Processed Crowns (D2710-D2792):A) Laboratory processed crowns on permanent teeth (or over-retained primary teeth with no permanentsuccessor) are a benefit only once in a 5 year period except when failure or breakage results fromcircumstances beyond the control of the provider (such as due to a patients oral habits).B) Prior authorization with current periapical and arch radiographs is required. Arch films are not requiredfor crown authorizations if the Medi-Cal Dental Program has paid for root canal treatment on the sametooth within the last six months. Only a periapical radiograph of the completed root canal treatment isrequired.C) A benefit for patients age 13 or older when a lesser service will not suffice because of extensive coronaldestruction. The following criteria shall be met for prior authorization:i) Anterior teeth shall show traumatic or pathological destruction to the crown of the tooth, whichinvolves at least one of the following:ii) the involvement of four or more surfaces including at least one incisal angle. The facial or lingualsurface shall not be considered involved for a mesial or proximal restoration unless the proximalrestoration wraps around the tooth to at least the midline,iii) the loss of an incisal angle which involves a minimum area of both half the incisal width and half theheight of the anatomical crown,iv) an incisal angle is not involved but more than 50% of the anatomical crown is involved.v) Bicuspids (premolars) shall show traumatic or pathological destruction of the crown of the tooth,which involves three or more tooth surfaces including one cusp.vi) Molars shall show traumatic or pathological destruction of the crown of the tooth, which involvesfour or more tooth surfaces including two or more cusps.vii) Posterior crowns for patients age 21 or older are a benefit only when they act as an abutment for aremovable partial denture with cast clasps or rests (D5213 and D5214) or for a fixed partial denturewhich meets current criteria.D) Restorative services provided solely to replace tooth structure lost due to attrition, abrasion, erosion orfor cosmetic purposes are not a benefit.E) Laboratory crowns are not a benefit when the prognosis of the tooth is questionable due to nonrestorability or periodontal involvement.F) Laboratory processed crowns are not a benefit when the tooth can be restored with an amalgam or resinbased composite.G) When a tooth has been restored with amalgam or resin-based composite restoration within 36 months,by the same provider, written documentation shall be submitted with the TAR justifying the medicalnecessity for the crown request. A current periapical radiograph dated after the restoration is required todemonstrate the medical necessity along with arch radiographs.H) Tooth and soft tissue preparation, crown lengthening, cement bases, direct and indirect pulp capping,amalgam or acrylic buildups, pins (D2951), bonding agents, lining agents, impressions, temporary crowns,

Effective June 1, 2014

Manual of CriteriaPage 5-23

Restorative General Policies (D2000-D2999)

occlusal adjustments (D9951), polishing, local anesthesia (D9210) and any other associated proceduresare included in the fee for a completed laboratory processed crown.I) Arch integrity and overall condition of the mouth, including the patients ability to maintain oral health,shall be considered for prior authorization, which shall be based upon a supportable 5 year prognosis forthe teeth to be crowned.J) Indirectly fabricated or prefabricated posts (D2952 and D2954) are a benefit when medically necessary forthe retention of allowable laboratory processed crowns on root canal treated permanent teeth.K) Partial payment will not be made for an undelivered laboratory processed crown. Payment shall be madeonly upon final cementation.

Manual of CriteriaPage 5-24

Effective June 1, 2014

Restorative Procedures (D2000-D2999)

Restorative Procedures (D2000-D2999)

PROCEDURE D2140

PROCEDURE D2330

Permanent teeth:

AMALGAM - ONE SURFACE,

PRIMARY OR PERMANENT

RESIN-BASED COMPOSITE - ONE

SURFACE, ANTERIOR

1.

Primary teeth:

Primary teeth:

2.

1.

1.

2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentrefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code andsurface code.A benefit once in a 12-monthperiod.

2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentrefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code andsurface code.A benefit once in a 12-monthperiod.

Permanent teeth:

Permanent teeth:

1.

1.

2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentRefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code andsurface code.A benefit once in a 36-monthperiod.

2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentRefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code andsurface code.A benefit once in a 36-monthperiod.

This procedure does not

require prior authorization.Radiographs for paymentRefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code andsurface code.A benefit once in a 36-monthperiod.Each unique tooth surface isonly payable once per toothper date of service.

2.

3.4.5.

This procedure does not

require prior authorization.Radiographs for paymentrefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code andsurface code.A benefit once in a 12-monthperiod.Each unique tooth surface isonly payable once per toothper date of service.

1.2.

3.4.5.

This procedure does not

require prior authorization.Radiographs for paymentrefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code.At least four surfaces shall beinvolved.A benefit once in a 12-monthperiod.

Manual of CriteriaPage 5-25

Restorative Procedures (D2000-D2999)

Permanent teeth:

PROCEDURE D2393

PROCEDURE D2543

1.

RESIN-BASED COMPOSITE THREE SURFACES, POSTERIOR

ONLAY - METALLIC - THREE

SURFACES

2.

3.4.5.

This procedure does not

require prior authorization.Radiographs for paymentrefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code.At least four surfaces shall beinvolved.A benefit once in a 36-monthperiod.

PROCEDURE D2391RESIN-BASED COMPOSITE - ONESURFACE, POSTERIOR

See the criteria under

Procedure D2391.

PROCEDURE D2394

PROCEDURE D2544

RESIN-BASED COMPOSITE - FOUR

OR MORE SURFACES, POSTERIOR

ONLAY - METALLIC - FOUR OR

MORE SURFACES

See the criteria under

Procedure D2391.

PROCEDURE D2610

GOLD FOIL - ONE SURFACE

INLAY - PORCELAIN/CERAMIC ONE SURFACE

This procedure is not a

benefit.

PROCEDURE D2420

1.

GOLD FOIL - TWO SURFACES

2.

3.4.

Permanent teeth:1.2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentRefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code andsurface code.A benefit once in a 36-monthperiod.

This procedure is not a

benefit.

PROCEDURE D2410

Primary teeth:This procedure does notrequire prior authorization.Radiographs for paymentrefer to Restorative GeneralPolicies for specificrequirements.Requires a tooth code andsurface code.A benefit once in a 12-monthperiod.

This procedure is not a

benefit.

This procedure is not a

benefit.

PROCEDURE D2620INLAY - PORCELAIN/CERAMIC TWO SURFACESThis procedure is not abenefit.

PROCEDURE D2630INLAY - PORCELAIN/CERAMIC THREE OR MORE SURFACESThis procedure is not abenefit.

PROCEDURE D2642ONLAY - PORCELAIN/CERAMIC TWO SURFACESThis procedure is not abenefit.

PROCEDURE D2643ONLAY - PORCELAIN/CERAMIC THREE SURFACESThis procedure is not abenefit.

PROCEDURE D2644ONLAY - PORCELAIN/CERAMIC FOUR OR MORE SURFACESThis procedure is not abenefit.

Effective June 1, 2014

Restorative Procedures (D2000-D2999)

PROCEDURE D2650INLAY - RESIN-BASED COMPOSITE- ONE SURFACE

3.4.

This procedure is not a

benefit.

PROCEDURE D2651INLAY - RESIN-BASED COMPOSITE- TWO SURFACES

5.

This procedure is not a

benefit.

PROCEDURE D2652INLAY - RESIN-BASED COMPOSITE- THREE OR MORE SURFACESThis procedure is not abenefit.

PROCEDURE D2662ONLAY- RESIN BASEDCOMPOSITE- TWO SURFACESThis procedure is not abenefit.

Effective June 1, 2014

Requires a tooth code.

A benefit:a. once in a five-yearperiod.b. for any resin basedcomposite crown that isindirectly fabricated.Not a benefit:a. for patients under theage of 13.b. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting removable partialdenture with cast claspsor rests.for use as a temporary crown.

4.5.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Photographs for priorauthorization a photographshall be submitted whenthere is an existing removablepartial denture and the castclasp or rest is not evident ona radiograph.Requires a tooth code.A benefit:a. once in a five-yearperiod.b. for any resin basedcomposite crown that isindirectly fabricated.c. only for the treatment ofposterior teeth acting asan abutment for anexisting removable partialdenture with cast claspsor rests (D5213 andD5214), or

d.

6.

when the treatment plan

includes an abutmentcrown and removablepartial denture (D5213 orD5214). Both shall besubmitted on the sameTAR for priorauthorization.Not a benefit:a. for 3rd molars, unless the3rd molar is an abutmentfor an existing removablepartial denture with castclasps or rests.b. for use as a temporarycrown.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Requires a tooth code.A benefit:a. once in a five-yearperiod.b. for any resin basedcomposite crown that isindirectly fabricated.Not a benefit:a. for patients under theage of 13.b. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting removable partialdenture with cast claspsor rests.c. for use as a temporarycrown.Manual of CriteriaPage 5-27

Restorative Procedures (D2000-D2999)

Permanent posterior teeth (age 21or older):1.2.

3.

4.5.

6.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Photographs for priorauthorization a photographshall be submitted whenthere is an existing removablepartial denture and the castclasp or rest is not evident ona radiograph.Requires a tooth code.A benefit:a. once in a five-yearperiod.b. for any resin basedcomposite crown that isindirectly fabricated.c. only for the treatment ofposterior teeth acting asan abutment for anexisting removable partialdenture with cast claspsor rests (D5213 andD5214), ord. when the treatment planincludes an abutmentcrown and removablepartial denture (D5213 orD5214). Both shall besubmitted on the sameTAR for priorauthorization.Not a benefit:a. for 3rd molars, unless the3rd molar is an abutmentfor an existing removablepartial denture with castclasps or rests.b. for use as a temporarycrown.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Requires a tooth code.A benefit once in a five-yearperiod.Not a benefit:a. for patients under theage of 13.b. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting removable partialdenture with cast claspsor rests.

Permanent posterior teeth (age 21

or older):1.2.

3.

4.5.Manual of CriteriaPage 5-28

a.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Photographs for priorauthorization- a photographshall be submitted whenthere is an existing removablepartial denture and the castclasps or rest is not evidenton a radiograph.Requires a tooth code.A benefit:

6.

once in a five-yearperiod.b. only for the treatment ofposterior teeth acting asan abutment for anexisting removable partialdenture with cast claspsor rests (D5213 andD5214), orc. when the treatment planincludes an abutmentcrown and removablepartial denture (D5213 orD5214). Both shall besubmitted on the sameTAR for priorauthorization.Not a benefit for 3rd molars,unless the 3rd molar is anabutment for an existingremovable partial denturewith cast clasps or rests.

PROCEDURE D2722CROWN - RESIN WITH NOBLEMETALThis procedure is not abenefit.

Restorative Procedures (D2000-D2999)

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Photographs for priorauthorization- a photographshall be submitted whenthere is an existing removablepartial denture and the castclasps or rest is not evidenton a radiograph.Requires a tooth code.A benefit:a. once in a five-yearperiod.b. only for the treatment ofposterior teeth acting asan abutment for anexisting removable partialdenture with cast claspsor rests (D5213 andD5214), orc. when the treatment planincludes an abutmentcrown and removablepartial denture (D5213 orD5214). Both shall besubmitted on the sameTAR for priorauthorization.Not a benefit for 3rd molars,unless the 3rd molar is anabutment for an existingremovable partial denturewith cast clasps or rests.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Requires a tooth code.A benefit once in a five-yearperiod.Not a benefit:a. for beneficiaries underthe age of 13.b. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting removable partialdenture with cast claspsor rests.

Permanent posterior teeth (age 21

or older):1.2.

3.

4.5.Effective June 1, 2014

a.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Photographs for priorauthorization- a photographshall be submitted whenthere is an existing removablepartial denture and the castclasps or rest is not evidenton a radiograph.Requires a tooth code.A benefit:

6.

once in a five-yearperiod.b. only for the treatment ofposterior teeth acting asan abutment for anexisting removable partialdenture with cast claspsor rests (D5213 andD5214), orc. when the treatment planincludes an abutmentcrown and removablepartial denture (D5213 orD5214). Both shall besubmitted on the sameTAR for priorauthorization.Not a benefit for 3rd molars,unless the 3rd molar is anabutment for an existingremovable partial denturewith cast clasps or rests.

abutment for an existing

Permanent posterior teeth (age 21

or older):

Permanent anterior teeth (age 13

or older) and permanent posteriorteeth (ages 13 through 20):

1.

1.

2.

3.

4.5.

6.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Photographs for priorauthorization- a photographshall be submitted whenthere is an existing removablepartial denture and the castclasps or rest is not evidenton a radiograph.Requires a tooth code.A benefit:a. once in a five- yearperiod.b. only for the treatment ofposterior teeth acting asan abutment for anexisting removable partialdenture with cast claspsor rests (D5213 andD5214), orc. when the treatment planincludes an abutmentcrown and removablepartial denture (D5213 orD5214). Both shall besubmitted on the sameTAR for priorauthorization.Not a benefit for 3rd molars,unless the 3rd molar is an

Manual of CriteriaPage 5-30

4.5.

2.

3.4.5.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Requires a tooth code.A benefit once in a five-yearperiod.Not a benefit:a. for patients under theage of 13.b. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting removable partialdenture with cast claspsor rests.

Permanent posterior teeth (age 21

or older):1.2.

3.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Photographs for priorauthorization- a photographshall be submitted whenthere is an existing removablepartial denture and the castclasps or rest is not evidenton a radiograph.

6.

Requires a tooth code.

A benefit:a. once in a five- yearperiod.b. only for the treatment ofposterior teeth acting asan abutment for anexisting removable partialdenture with cast claspsor rests (D5213 andD5214), orc. when the treatment planincludes an abutmentcrown and removablepartial denture (D5213 orD5214). Both shall besubmitted on the sameTAR for priorauthorization.Not a benefit for 3rd molars,unless the 3rd molar is anabutment for an existingremovable partial denturewith cast clasps or rests.

PROCEDURE D2790CROWN - FULL CAST HIGH NOBLEMETALThis procedure is not abenefit.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Requires a tooth code.A benefit once in a five-yearperiod.Not a benefit:a. for patients under theage of 13.Effective June 1, 2014

Restorative Procedures (D2000-D2999)

b.

for 3rd molars, unless the

Permanent posterior teeth (age 21

or older):1.2.

3.

4.5.

6.

Prior authorization isrequired.Radiographs for priorauthorization - submit archand periapical radiographs.Photographs for priorauthorization- a photographshall be submitted whenthere is an existing removablepartial denture and the castclasps or rest is not evidenton a radiograph.Requires a tooth code.A benefit:a. once in a five- yearperiod.b. only for the treatment ofposterior teeth acting asan abutment for anexisting removable partialdenture with cast claspsor rests (D5213 andD5214), orc. when the treatment planincludes an abutmentcrown and removablepartial denture (D5213 orD5214). Both shall besubmitted on the sameTAR for priorauthorization.Not a benefit for 3rd molars,unless the 3rd molar is anabutment for an existingremovable partial denturewith cast clasps or rests.

This procedure is not a

This procedure is not a

benefit.

PROCEDURE D2910

5.

RECEMENT INLAY, ONLAY, OR

PARTIAL COVERAGERESTORATION1.2.

3.4.

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.A benefit once in a 12-monthperiod, per provider.

PROCEDURE D2915RECEMENT CAST ORPREFABRICATED POST AND COREThis procedure is to beperformed in conjunctionwith the recementation of anexisting crown or of a newcrown and is not payableseparately.

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.The original provider isresponsible for all recementations within the first12 months following theinitial placement ofprefabricated or laboratoryprocessed crowns.Not a benefit within 12months of a previous recementation by the sameprovider.

PROCEDURE D2929PREFABRICATEDPORCELAIN/CERAMIC CROWN PRIMARY TOOTH1.2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentsubmit pre-operativeradiographs. Refer toRestorative General Policiesfor specific requirements.Requires a tooth code.A benefit once in a 12-monthperiod.

PREFABRICATED STAINLESS STEEL

PREFABRICATED STAINLESS STEEL

This procedure does not

require prior authorization.Radiographs for paymentsubmit arch and pre-operativeperiapical radiographs. Referto Restorative GeneralPolicies for specificrequirements.Requires a tooth code.A benefit once in a 36-monthperiod.Not a benefit for 3rd molars,unless the 3rd molar occupiesthe 1st or 2nd molar position.

PROCEDURE D2932PREFABRICATED RESIN CROWNPrimary teeth:1.2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentsubmit pre-operativeradiographs. Refer toRestorative General Policiesfor specific requirements.Requires a tooth code.A benefit once in a 12-monthperiod.

1.2.

3.4.5.

2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentsubmit arch and pre-operativeperiapical radiographs. Referto Restorative GeneralPolicies for specificrequirements.Requires a tooth code.A benefit once in a 36-monthperiod.

Manual of CriteriaPage 5-32

PROTECTIVE RESTORATION1.2.

3.4.

5.

6.

Permanent teeth:1.2.

3.4.5.

Permanent teeth:1.

This procedure does not

require prior authorization.Radiographs for paymentsubmit pre-operativeradiographs. Refer toRestorative General Policiesfor specific requirements.Requires a tooth code.A benefit once in a 12-monthperiod.This procedure includes theplacement of a resin-basedcomposite.

PROCEDURE D2940

6.

This procedure does not

require prior authorization.Radiographs for paymentsubmit arch and pre-operativeperiapical radiographs. Referto Restorative GeneralPolicies for specificrequirements.Requires a tooth code.A benefit once in a 36-monthperiod.Not a benefit for 3rd molars,unless the 3rd molar occupiesthe 1st or 2nd molar position.This procedure includes theplacement of a resin-basedcomposite.

This procedure cannot be

prior authorized.Radiographs for payment submit pre-operativeradiographs. Refer toRestorative General Policiesfor specific requirements.Requires a tooth code.A benefit once per tooth in asix-month period, perprovider.Not a benefit:a. when performed on thesame date of service witha permanent restorationor crown, for same tooth.b. on root canal treatedteeth.This procedure is for atemporary restoration and isnot to be used as a base orliner under a restoration.

PROCEDURE D2950CORE BUILDUP, INCLUDING ANYPINSThis procedure is included inthe fee for restorativeprocedures and is not payableseparately.

This procedure does not

require prior authorization.Radiographs for paymentsubmit pre-operativeradiographs.Requires a tooth code.A benefit:a. for permanent teethonly.b. when billed with anamalgam or compositeEffective June 1, 2014

Restorative Procedures (D2000-D2999)

c.

d.

e.

restoration on the same

date of service.once per tooth regardlessof the number of pinsplaced.for a posteriorrestoration when thedestruction involvesthree or more connectedsurfaces and at least onecusp, orfor an anteriorrestoration whenextensive coronaldestruction involves theincisal angle.

PROCEDURE D2954

PROCEDURE D2961

PREFABRICATED POST AND CORE

IN ADDITION TO CROWN

LABIAL VENEER (RESIN

This procedure does not

require prior authorization.Radiographs for paymentsubmit arch and periapicalradiographs.Requires a tooth code.A benefit:a. once per tooth regardlessof number of postsplaced.b. only in conjunction withallowable crowns(prefabricated orlaboratory processed) onroot canal treatedpermanent teeth.This procedure shall besubmitted on the sameclaim/TAR as the crownrequest.

PROCEDURE D2953EACH ADDITIONAL INDIRECTLYFABRICATED POST - SAME TOOTHThis procedure is to beperformed in conjunctionwith D2952 and is not payableseparately.Effective June 1, 2014

5.

This procedure does not

require prior authorization.Radiographs for paymentsubmit arch and periapicalradiographs.Requires a tooth code.A benefit:a. once per tooth regardlessof number of postsplaced.b. only in conjunction withallowable crowns(prefabricated orlaboratory processed) onroot canal treatedpermanent teeth.This procedure shall besubmitted on the sameclaim/TAR as the crownrequest.

This procedure is to be performed

This procedure cannot be

prior authorized.Radiographs for payment submit a pre-operativeperiapical radiograph.Written documentation forpayment - shall include adescription of thecircumstances leading to thetraumatic injury.Requires a tooth code.A benefit:a. once per tooth, perprovider.b. for permanent teethonly.Not a benefit on the samedate of service as:a. palliative (emergency)treatment of dental painminor procedure(D9110).b. office visit forobservation (duringregularly scheduledhours) - no other servicesperformed (D9430).This procedure is limited tothe palliative treatment oftraumatic injury only and shallmeet the criteria for alaboratory processed crown(D2710-D2792).Manual of CriteriaPage 5-33

This procedure does not

require prior authorization.Radiographs for payment submit radiographs asapplicable for the type ofprocedure.Photographs for payment submit photographs asapplicable for the type ofprocedure.Written documentation forpayment shall describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity, anypertinent history and theproposed or actual treatment.Requires a tooth code.D2999 shall be used:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patientEffective June 1, 2014

Endodontic General Policies (D3000-D3999)

Endodontic General Policies (D3000-D3999)

1.

2.

3.

4.

5.

6.7.

8.9.

Prior authorization with current periapical radiographs is required for initial root canal therapy (D3310, D3320and D3330), root canal retreatment (D3346, D3347 and D3348), partial pulpotomy for apexogenesis (D3222),apexification/recalcification (D3351) and apicoectomy/periradicular surgery (D3410, D3421, D3425 andD3426) on permanent teeth.Prior authorization for root canal therapy (D3310, D3320 and D3330) is not required when it is documented ona claim for payment that the permanent tooth has been accidentally avulsed or there has been a fracture ofthe crown exposing vital pulpal tissue. Preoperative radiographs (arch and periapicals) shall be submitted forpayment.Root canal therapy (D3310, D3320, D3330, D3346, D3347 and D3348) is a benefit for permanent teeth andover-retained primary teeth with no permanent successor, if medically necessary. It is medically necessarywhen the tooth is non-vital (due to necrosis, gangrene or death of the pulp) or if the pulp has beencompromised by caries, trauma or accident that may lead to the death of the pulp.The prognosis of the affected tooth and other remaining teeth shall be evaluated in considering endodonticprocedures for prior authorization and payment. Endodontic procedures are not a benefit when the prognosisof the tooth is questionable (due to non-restorability or periodontal involvement).Endodontic procedures are not a benefit when extraction is appropriate for a tooth due to non-restorability,periodontal involvement or for a tooth that is easily replaced by an addition to an existing or proposedprosthesis in the same arch.Endodontic procedures are not a benefit for 3rd molars, unless the 3rd molar occupies the 1st or 2nd molarpositions or is an abutment for an existing fixed or removable partial denture with cast clasps or rests.The fee for endodontic procedures includes all treatment and post treatment radiographs, any temporaryrestorations and/or occlusal seals, medicated treatments, bacteriologic studies, pulp vitality tests, removal ofroot canal obstructions (such as posts, silver points, old root canal filling material, broken root canal files andbroaches and calcifications), internal root repairs of perforation defects and routine postoperative care within30 days.Endodontic procedures shall be completed prior to payment. The date of service on the payment request shallreflect the final treatment date. A post treatment radiograph is not required for payment.Satisfactory completion of endodontic procedures is required prior to requesting the final restoration.

Effective June 1, 2014

Manual of CriteriaPage 5-35

Endodontic General Policies (D3000-D3999)

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Manual of CriteriaPage 5-36

Effective June 1, 2014

Endodontic Procedures (D3000-D3999)

Endodontic Procedures (D3000-D3999)

PROCEDURE D3110

portion of the pulp coronal to

the dentinocemental junctionwith the aim of maintainingthe vitality of the remainingradicular portion by means ofan adequate dressing.

PULP CAP - DIRECT (EXCLUDING

FINAL RESTORATION)This procedure is included inthe fees for restorative andendodontic procedures and isnot payable separately.

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.A benefit once per primarytooth.Not a benefit:a. for a primary tooth nearexfoliation.b. for a primary tooth with anecrotic pulp or aperiapical lesion.c. for a primary tooth that isnon-restorable.d. for a permanent tooth.This procedure is for thesurgical removal of the entire

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.A benefit:a. for permanent teeth.b. for over-retained primaryteeth with no permanentsuccessor.c. once per tooth.Not a benefit on the samedate of service with anyadditional services, sametooth.This procedure is for the reliefof acute pain prior toconventional root canaltherapy and is not a benefitfor root canal therapyvisits.Subsequent emergencyvisits, if medically necessary,shall be billed as palliative(emergency) treatment ofdental pain- minor procedure(D9110).

2.

3.4.

5.

6.

Prior authorization isrequired.Radiographs for priorauthorization - submitperiapical radiographs.Requires a tooth code.A benefit:a. once per permanenttooth.b. for patients under theage of 21.Not a benefit:a. for primary teeth.b. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting fixed partialdenture or removablepartial denture with castclasps or rests.c. on the same date ofservice as any otherendodontic proceduresfor the same tooth.This procedure is for vitalteeth only.

This procedure does not

Endodontic Procedures (D3000-D3999)

3.4.5.

necessity is not required for

payment.Requires a tooth code.A benefit once per primarytooth.Not a benefit:a. for a primary tooth nearexfoliation.b. with a therapeuticpulpotomy (excludingfinal restoration)(D3220), same date ofservice, same tooth.c. with pulpal debridement,primary and permanentteeth (D3221), same dateof service, same tooth.

PROCEDURE D3240

PROCEDURE D3310

PROCEDURE D3330

ENDODONTIC THERAPY,ANTERIOR TOOTH (EXCLUDINGFINAL RESTORATION)

ENDODONTIC THERAPY, MOLAR

TOOTH (EXCLUDING FINALRESTORATION)

1.

1.

2.

3.4.

5.

PULPAL THERAPY (RESORBABLE

FILLING) - POSTERIOR, PRIMARYTOOTH (EXCLUDING FINALRESTORATION)1.2.

3.4.5.

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.A benefit once per primarytooth.Not a benefit:a. for a primary tooth nearexfoliation.b. with a therapeuticpulpotomy (excludingfinal restoration)(D3220), same date ofservice, same tooth.c. with pulpal debridement,primary and permanentteeth (D3221), same dateof service, same tooth.

Prior authorization isrequired.Radiographs for priorauthorization - submitperiapical radiographs.Requires a tooth code.A benefit:a. once per permanenttooth.b. for patients under theage of 21.Not a benefit:a. for primary teeth.b. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting fixed partialdenture or removablepartial denture with castclasps or rests.c. on the same date ofservice as any otherendodontic proceduresfor the same tooth.This procedure includes initialopening of the tooth,performing a pulpectomy,preparation of canal spaces,placement of medications andall treatment and posttreatment radiographs.If an interim medicationreplacement is necessary, useapexification/recalcificationinterim medicationreplacement (apicalclosure/calcific repair of

Prior authorization is required

for D3351, which shall becompleted before D3352 ispayable.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.A benefit:a. only followingapexification/recalcification- initial visit(apical closure/calcificrepair of perforations,root resorption, etc.)(D3351).b. once per permanenttooth.c. for patients under theage of 21.Not a benefit:a. for primary teeth.b. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting fixed partialdenture or removable

Manual of CriteriaPage 5-40

6.

7.

partial denture with cast

clasps or rests.c. on the same date ofservice as any otherendodontic proceduresfor the same tooth.This procedure includesreopening the tooth,placement of medications andall treatment and posttreatment radiographs.Upon completion ofapexification/recalcification,prior authorization for thefinal root canal therapy shallbe submitted along with thepost treatment radiograph todemonstrate sufficient apicalformation.

Endodontic Procedures (D3000-D3999)

4.5.6.

7.

8.

medical necessity is not

evident on the radiographs,documentation shall includethe rationale and the identityof the root that requirestreatment.Requires a tooth code.A benefit for permanentbicuspid teeth only.Not a benefit:a. to the original providerwithin 90 days of rootcanal therapy exceptwhen a medical necessityis documented.b. to the original providerwithin 24 months of aprior apicoectomy/periradicular surgery,same root.The fee for this procedureincludes the placement ofretrograde filling material andall treatment and posttreatment radiographs.If more than one root istreated, useapicoectomy/periradicularsurgery - each additional root(D3426).

Effective June 1, 2014

of the root that requires

treatment.Requires a tooth code.A benefit for permanent 1stand 2nd molar teeth only.Not a benefit:a. to the original providerwithin 90 days of rootcanal therapy exceptwhen a medical necessityis documented.b. to the original providerwithin 24 months of aprior apicoectomy/periradicular surgery,same root.c. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting fixed partialdenture or removablepartial denture with castclasps or rests.The fee for this procedureincludes the placement ofretrograde filling material andall treatment and posttreatment radiographs.If more than one root istreated, useapicoectomy/periradicularsurgery - each additional root(D3426).

medical necessity is not

evident on the radiographs,documentation shall includethe rationale and the identityof the root that requirestreatment.Requires a tooth code.A benefit for permanent teethonly.Not a benefit:a. to the original providerwithin 90 days of rootcanal therapy exceptwhen a medical necessityis documented.b. to the original providerwithin 24 months of aprior apicoectomy/periradicular surgery,same root.c. for 3rd molars, unless the3rd molar occupies the1st or 2nd molar positionor is an abutment for anexisting fixed partialdenture or removablepartial denture with castclasps or rests.Only payable the same dateof service as proceduresD3421 or D3425.The fee for this procedureincludes the placement ofretrograde filling material andall treatment and posttreatment radiographs.

PROCEDURE D3430RETROGRADE FILLING - PER ROOTThis procedure is to beperformed in conjunctionwith endodontic proceduresand is not payable separately.

PROCEDURE D3450ROOT AMPUTATION PER ROOTThis procedure is not abenefit.Manual of CriteriaPage 5-41

Photographs for paymentsubmit as applicable for the

type of procedure.Written documentation forpayment shall describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity, anypertinent history and theactual treatment.Requires a tooth code.Procedure D3999 shall beused:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patienthas an exceptionalmedical condition tojustify the medicalnecessity.Documentation shallinclude the medicalcondition and the specificCDT code associated withthe treatment.

This procedure does not

Effective June 1, 2014

Periodontal General Policies (D4000-D4999)

Periodontal General Policies (D4000-D4999)`

1.

2.3.

4.5.

6.

7.

8.

9.

10.

11.

12.13.

Periodontal procedures shall be a benefit for patients age 13 or older. Periodontal procedures shall beconsidered for patients under the age of 13 when unusual circumstances exist such as aggressive periodontitisand drug-induced hyperplasia and the medical necessity has been fully documented on the TAR.Prior authorization is required for all periodontal procedures except for unscheduled dressing change (bysomeone other than the treating dentist) (D4290) and periodontal maintenance (D4910).Current periapical radiographs of the involved areas and bitewing radiographs are required for periodontalscaling and root planing (D4341 and D4342) and osseous surgery (D4260 and D4261) for prior authorizations.A panoramic radiographic image alone is non- diagnostic for periodontal procedures.Photographs are required for gingivectomy or gingivoplasty (D4210 and D4211) for prior authorizations.Only teeth that qualify as diseased are to be considered in the count for the number of teeth to be treated in aparticular quadrant. A qualifying tooth shall have a significant amount of bone loss, presence of calculusdeposits, be restorable and have arch integrity and shall meet Medi-Cal Dental Program criteria for therequested procedure. Qualifying teeth include implants. Teeth shall not be counted as qualifying when theyare indicated to be extracted. Full or partial quadrants are defined as follows:A) a full quadrant is considered to have four or more qualifying diseased teeth,B) a partial quadrant is considered to have one, two, or three diseased teeth,C) third molars shall not be counted unless the third molar occupies the first or second molar position or isan abutment for an existing fixed or removable partial denture with cast clasps or rests.Tooth bounded spaces shall only be counted in conjunction with osseous surgeries (D4260 and D4261) thatrequire a surgical flap. Each tooth bounded space shall only count as one tooth space regardless of thenumber of missing natural teeth in the space.Scaling and root planing (D4341 and D4342) are a benefit once per quadrant in a 24 month period. Patientsshall exhibit connective tissue attachment loss and radiographic evidence of bone loss and/or subgingivalcalculus deposits on root surfaces.Gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261) are a benefit onceper quadrant in a 36 month period and shall not be authorized until 30 days following scaling and root planing(D4341 and D4342) in the same quadrant. Patients shall exhibit radiographic evidence of moderate to severebone loss to qualify for osseous surgery.Gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261) includes threemonths of post-operative care and any surgical re-entry for 36 months. Documentation of extraordinarycircumstances and/or medical conditions will be given consideration on a case-by- case basis.Scaling and root planing (D4341 and D4342) can be authorized in conjunction with prophylaxis procedures(D1110 and D1120). However, payment shall not be made for any prophylaxis procedure if the prophylaxis isperformed on the same date of service as the scaling and root planing.Gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261) includesfrenulectomy (frenectomy or frenotomy) (D7960), frenuloplasty (D7963) and/or distal wedge performed in thesame area on the same date of service.Procedures involved in acquiring graft tissues (hard or soft) from extra-oral donor sites are considered part ofthe fee for osseous surgery (D4260 and D4261) and are not payable separately.Gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261) performed inconjunction with a laboratory crown, prefabricated crown, amalgam or resin-based composite restoration orendodontic therapy is included in the fee for the final restoration or endodontic therapy and is not payableseparately.

Effective June 1, 2014

Manual of CriteriaPage 5-43

Periodontal General Policies (D4000-D4999)

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Manual of CriteriaPage 5-44

Effective June 1, 2014

Periodontal Procedures (D4000-D4999)

Periodontal Procedures (D4000-D4999)

Prior authorization isrequired.Photographs for priorauthorization- submitphotographs of the involvedareas.Requires a quadrant code.If three or fewer diseasedteeth are present in thequadrant, use gingivectomyor gingivoplasty (D4211).A benefit:a. for patients age 13 orolder.b. once per quadrant every36 months.This procedure cannot beprior authorized within 30days following periodontalscaling and root planing(D4341 and D4342) for thesame quadrant.

Prior authorization isrequired.Photographs for priorauthorization- submitphotographs of the involvedareas.Requires a quadrant code.If four or more diseased teethare present in the quadrant,

Effective June 1, 2014

5.

6.

use gingivectomy orgingivoplasty (D4210).A benefit:a. for patients age 13 orolder.b. once per quadrant every36 months.This procedure cannot beprior authorized within 30days following periodontalscaling and root planing(D4341 and D4342) for thesame quadrant.

PROCEDURE D4212GINGIVECTOMY ORGINGIVOPLASTY TO ALLOWACCESS FOR RESTORATIVEPROCEDURE, PER TOOTHThis procedure is not abenefit.

PROCEDURE D4230ANATOMICAL CROWNEXPOSURE- FOUR OR MORECONTIGUOUS TEETH PERQUADRANTThis procedure is not abenefit.

PROCEDURE D4260OSSEOUS SURGERY (INCLUDINGFLAP ENTRY AND CLOSURE)FOUR OR MORE CONTIGUOUSTEETH OR TOOTH BOUNDEDSPACES PER QUADRANT1.2.

ANATOMICAL CROWNEXPOSURE- ONE TO THREE TEETHPER QUADRANTThis procedure is not abenefit.

3.4.

PROCEDURE D4240GINGIVAL FLAP PROCEDURE,INCLUDING ROOT PLANINGFOUR OR MORE CONTIGUOUSTEETH OR TOOTH BOUNDEDSPACES PER QUADRANTThis procedure is not abenefit.

5.

6.

Prior authorization isrequired.Radiographs for priorauthorization- submitperiapical radiographs of theinvolved areas and bitewingradiographs.Requires a quadrant code.If three or fewer diseasedteeth are present in thequadrant, use osseoussurgery (D4261).A benefit:a. for patients age 13 orolder.b. once per quadrant every36 months.This procedure cannot beprior authorized within 30Manual of CriteriaPage 5-45

Periodontal Procedures (D4000-D4999)

7.

days following periodontal

scaling and root planing(D4341 and D4342) for thesame quadrant.This procedure can only beprior authorized whenpreceded by periodontalscaling and root planning(D4341 and D4342) in thesame quadrant within theprevious 24 months.

Prior authorization isrequired.Radiographs for priorauthorization- submitperiapical radiographs of theinvolved areas and bitewingradiographs.Requires a quadrant code.If four or more diseased teethare present in the quadrant,use osseous surgery (D4260).A benefit:a. for patients age 13 orolder.b. once per quadrant every36 months.This procedure cannot beprior authorized within 30days following periodontalscaling and root planing(D4341 and D4342) for thesame quadrant.This procedure can only beprior authorized whenpreceded by periodontalscaling and root planing(D4341 and D4342) in thesame quadrant within theprevious 24 months.

Manual of CriteriaPage 5-46

PROCEDURE D4263

PROCEDURE D4273

BONE REPLACEMENT GRAFT

FIRST SITE IN QUADRANT

SUBEPITHELIAL CONNECTIVETISSUE GRAFT PROCEDURES, PERTOOTH

This procedure is not a

benefit.

PROCEDURE D4264BONE REPLACEMENT GRAFT EACH ADDITIONAL SITE INQUADRANTThis procedure is not abenefit.

PROCEDURE D4265BIOLOGIC MATERIALS TO AID INSOFT AND OSSEOUS TISSUEREGENERATIONThis procedure is included inthe fees for other periodontalprocedures and is not payableseparately.

This procedure is not a

benefit.

PROCEDURE D4274PROCEDURE DISTAL ORPROXIMAL WEDGE PROCEDURE(WHEN NOT PERFORMED INCONJUNCTION WITH SURGICALPROCEDURES IN THE SAMEANATOMICAL AREA)This procedure is not abenefit.

This procedure is not a

This procedure is not a

Prior authorization isrequired.Radiographs for priorauthorization - submitperiapical radiographs of theinvolved areas and bitewingradiographs.Requires a quadrant code.If three or fewer diseasedteeth are present in thequadrant, use periodontalscaling and root planing(D4342).A benefit:a. for patients age 13 orolder.b. once per quadrant every24 months.Gingivectomy or gingivoplasty(D4210 and D4211) andosseous surgery (D4260 andD4261) cannot be priorauthorized within 30 daysfollowing this procedure forthe same quadrant.Prophylaxis (D1110 andD1120) are not payable onthe same date of service asthis procedure.

Effective June 1, 2014

3.4.

5.

6.

7.

Prior authorization isrequired.Radiographs for priorauthorization - submitperiapical radiographs of theinvolved areas and bitewingradiographs.Requires a quadrant code.If four or more diseased teethare present in the quadrant,use periodontal scaling androot planing (D4341).A benefit:a. for patients age 13 orolder.b. once per quadrant every24 months.Gingivectomy or gingivoplasty(D4210 and D4211) andosseous surgery (D4260 andD4261) cannot be priorauthorized within 30 daysfollowing this procedure forthe same quadrant.Prophylaxis (D1110 andD1120) are not payable onthe same date of service asthis procedure.

This procedure is included in

the fees for other periodontalprocedures and is not payableseparately.

PROCEDURE D4910PERIODONTAL MAINTENANCE1.2.

3.

4.

This procedure is included in

the fees for other periodontalprocedures and is not payableseparately.5.

This procedure does not

require prior authorization.A benefit:a. only for patients residingin a Skilled NursingFacility (SNF) orIntermediate Care Facility(ICF).b. only when preceded by aperiodontal scaling androot planing (D4341D4342).c. only after completion ofall necessary scaling androot planings.d. once in a calendarquarter.e. only in the 24 monthperiod following the lastscaling and root planing.Not a benefit in the samecalendar quarter as scalingand root planing.Not payable to the sameprovider in the same calendarquarter as prophylaxis- adult(D1110) or prophylaxis- child(D1120).This procedure is considered afull mouth treatment.

Manual of CriteriaPage 5-47

Periodontal Procedures (D4000-D4999)

PROCEDURE D4920

5.

UNSCHEDULED DRESSINGCHANGE (BY SOMEONE OTHERTHAN TREATING DENTIST)

6.

1.2.

3.

4.

This procedure cannot be

prior authorized.Written documentation forpayment shall include abrief description indicatingthe medical necessity.A benefit:a. for patients age 13 orolder.b. once per patient perprovider.c. within 30 days of thedate of service ofgingivectomy orgingivoplasty (D4210 andD4211) and osseoussurgery (D4260 andD4261).Unscheduled dressingchanges by the same providerare considered part of, andincluded in the fee forgingivectomy or gingivoplasty(D4210 and D4211) andosseous surgery (D4260 andD4261).

7.

Requires a tooth or quadrant

code, as applicable for thetype of procedure.A benefit for patients age 13or older.Procedure D4999 shall beused:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patienthas an exceptionalmedical condition tojustify the medicalnecessity.Documentation shallinclude the medicalcondition and the specificCDT code associated withthe treatment.

Effective June 1, 2014

Prosthodontics (Removable) General Policies (D5000-D5899)

Prosthodontics (Removable) General Policies (D5000-D5899)

1.

Complete and Partial Dentures (D5110-D5214 and D5860):

A) Prior authorization is required for removable prostheses except for immediate dentures (D5130 andD5140).B) Prior authorization shall be considered for a new prosthesis only when it is clearly evident that theexisting prosthesis cannot be made serviceable by repair, replacement of broken and missing teeth orreline.C) Current radiographs of all remaining natural teeth and implants and a properly completed prostheticJustification of Need For Prosthesis Form, DC054 (10/05) are required for prior authorization. A panoramicradiographic image shall be considered diagnostic for edentulous areas only.D) Complete and partial dentures are prior authorized only as full treatment plans. Payment shall be madeonly when the full treatment has been completed. Any revision of a prior authorized treatment planrequires a new TAR.E) New complete or partial dentures shall not be prior authorized when it would be highly improbable for apatient to utilize, care for or adapt to a new prosthesis due to psychological and/or motor deficiencies asdetermined by a clinical screening dentist (see g below).F) All endodontic, restorative and surgical procedures for teeth that impact the design of a removable partialdenture (D5211, D5212, D5213 and D5214) shall be addressed before prior authorization is considered.G) The need for new or replacement prosthesis may be evaluated by a clinical screening dentist.H) Providers shall use the laboratory order date as the date of service when submitting for payment of aprior authorized removable prosthesis. The laboratory order date is the date when the prosthesis is sentto the laboratory for final fabrication. Full payment shall not be requested until the prosthesis is deliveredand is in use by the patient.I) Partial payment of an undeliverable completed removable prosthesis shall be considered when thereason for non-delivery is adequately documented on the Notice of Authorization (NOA) and isaccompanied by a laboratory invoice indicating the prosthesis was processed. The completed prosthesisshall be kept in the providers office, in a deliverable condition, for a period of at least one year.J) A removable prosthesis is a benefit only once in a five year period. When adequately documented, thefollowing exceptions shall apply:i) Catastrophic loss beyond the control of the patient. Documentation must include a copy of theofficial public service agency report (fire or police), orii) A need for a new prosthesis due to surgical or traumatic loss of oral-facial anatomic structure, oriii) The removable prosthesis is no longer serviceable as determined by a clinical screening dentist.K) Prosthodontic services provided solely for cosmetic purposes are not a benefit.L) Temporary or interim dentures to be used while a permanent denture is being constructed are not abenefit.M) Spare or backup dentures are not a benefit.N) Evaluation of a denture on a maintenance basis is not a benefit.O) The fee for any removable prosthesis, reline, tissue conditioning or repair includes all adjustmentsnecessary for six months after the date of service by the same provider.P) Immediate dentures should only be considered for a patient when one or more of the followingconditions exist:i) extensive or rampant caries are exhibited in the radiographs,ii) severe periodontal involvement is indicated in the radiographs,iii) numerous teeth are missing resulting in diminished masticating ability adversely affecting thepatients health.Q) There is no insertion fee payable to an oral surgeon who seats an immediate denture.

Effective June 1, 2014

Manual of CriteriaPage 5-49

Prosthodontics (Removable) General Policies (D5000-D5899)

2.

R) Preventative, endodontic or restorative procedures are not a benefit for teeth to be retained foroverdentures. Only extractions for the retained teeth will be a benefit.S) Partial dentures are not a benefit to replace missing 3rd molars.Relines and Tissue Conditioning (D5730-D5761, D5850 and D5851):A) Laboratory relines (D5750, D5751, D5760 and D5761) are a benefit six months after the date of service forimmediate dentures (D5130 and D5140), an immediate overdenture (D5860) and cast metal partialdentures (D5213 and D5214) that required extractions.B) Laboratory relines (D5750, D5751, D5760 and D5761) are a benefit 12 months after the date of service forcomplete (remote) dentures (D5110 and D5120), a complete (remote) overdenture (D5860) and castmetal partial dentures (D5213 and D5214) that did not require extractions.C) Laboratory relines (D5760 and D5761) are not a benefit for resin based partial dentures (D5211andD5212).D) Laboratory relines (D5750, D5751, D5760 and D5761) are not a benefit within 12 months of chairsiderelines (D5730, D5731, D5740 and D5741).E) Chairside relines (D5730, D5731, D5740 and D5741) are a benefit six months after the date of service forimmediate dentures (D5130 and D5140), an immediate overdenture (D5860), resin based partial dentures(D5211 and D5212) and cast metal partial dentures (D5213 and D5214) that required extractions.F) Chairside relines (D5730, D5731, D5740 and D5741) are a benefit 12 months after the date of service forcomplete (remote) dentures (D5110 and D5120), a complete (remote) overdenture (D5860), resin basedpartial dentures (D5211 and D5212) and cast metal partial dentures (D5213 and D5214) that did notrequire extractions.G) Chairside relines (D5730, D5731, D5740 and D5741) are not a benefit within 12 months of laboratoryrelines (D5750, D5751, D5760 and D5761).H) Tissue conditioning (D5850 and D5851) is only a benefit to heal unhealthy ridges prior to a definitiveprosthodontic treatment.I) Tissue conditioning (D5850 and D5851) is a benefit the same date of service as an immediate prosthesisthat required extractions.

Manual of CriteriaPage 5-50

Effective June 1, 2014

Prosthodontic (Removable) Procedures (D5000-D5899)

Prosthodontic (Removable) Procedures (D5000-D5899)

PROCEDURE D5110

3.

COMPLETE DENTURE MAXILLARY1.2.

3.

4.

5.

6.

7.

Prior authorization isrequired.Radiographs for priorauthorization submitradiographs of all opposingnatural teeth.A current and completeJustification of Need ForProsthesis Form, DC054(10/05) is required for priorauthorization.A benefit once in a five yearperiod from a previouscomplete, immediate oroverdenture- completedenture.For an immediate denture,use immediate denturemaxillary (D5130) oroverdenture- complete, byreport (D5860) as applicablefor the type of procedure.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.A laboratory reline (D5750) orchairside reline (D5730) is abenefit 12 months after thedate of service for thisprocedure.

4.

5.

6.

7.

1.2.

Prior authorization isrequired.Radiographs for priorauthorization submitradiographs of all opposingnatural teeth.

Effective June 1, 2014

5.

6.

IMMEDIATE DENTURE MAXILLARY1.2.

3.4.

Prior authorization is not

required.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once per patient.Not a benefit as a temporarydenture. Subsequentcomplete dentures are not abenefit within a five-yearperiod of an immediatedenture.

All adjustments made for six

months after the date ofservice, by the same provider,are included in the fee for thisprocedure.A laboratory reline (D5750) orchairside reline (D5730) is abenefit six months after thedate of service for thisprocedure.

PROCEDURE D5140IMMEDIATE DENTURE MANDIBULAR1.2.

3.4.

PROCEDURE D5130

PROCEDURE D5120COMPLETE DENTURE MANDIBULAR

A current and complete

Justification of Need ForProsthesis Form, DC054(10/05) is required for priorauthorization.A benefit once in a five yearperiod from a previouscomplete, immediate oroverdenture- completedenture.For an immediate denture,use immediate denturemandibular (D5140) oroverdenture-complete, byreport (D5860) as applicablefor the type of procedure.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.A laboratory reline (D5751) orchairside reline (D5731) is abenefit 12 months after thedate of service for thisprocedure.

5.

6.

Prior authorization is not

required.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit once per patient.Not a benefit as a temporarydenture. Subsequentcomplete dentures are not abenefit within a five-yearperiod of an immediatedenture.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.A laboratory reline (D5751) orchairside reline (D5731) is abenefit six months after thedate of service for thisprocedure.

Manual of CriteriaPage 5-51

Prosthodontic (Removable) Procedures (D5000-D5899)

PROCEDURE D5211

9.

MAXILLARY PARTIAL DENTURE

RESIN BASE (INCLUDING ANYCONVENTIONAL CLASPS, RESTSAND TEETH)1.2.

3.

4.5.

6.7.

8.

Prior authorization isrequired.Radiographs for priorauthorization submitradiographs of all remainingnatural teeth and periapicalradiographs of abutmentteeth.A current and completeJustification of Need ForProsthesis Form, DC054(10/05) is required for priorauthorization.A benefit once in a five-yearperiod.A benefit when replacing apermanent anteriortooth/teeth and/or the archlacks posterior balancedocclusion. Lack of posteriorbalanced occlusion is definedas follows:a. five posterior permanentteeth are missing,(excluding 3rd molars), orb. all four 1st and 2ndpermanent molars aremissing, orc. the 1st and 2ndpermanent molars and2nd bicuspid are missingon the same side.Not a benefit for replacingmissing 3rd molars.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.Laboratory reline (D5760) isnot a benefit for thisprocedure.

Manual of CriteriaPage 5-52

Chairside reline (D5740) is a

benefit:a. once in a 12-monthperiod.b. six months after the dateof service for a partialdenture that requiredextractions, orc. 12 months after the dateof service for a partialdenture that did notrequire extractions.

PROCEDURE D5212

6.7.

8.

9.

MANDIBULAR PARTIAL DENTURE

RESIN BASE (INCLUDING ANYCONVENTIONAL CLASPS, RESTSAND TEETH)1.2.

3.

4.5.

Prior authorization isrequired.Radiographs for priorauthorization submitradiographs of all remainingnatural teeth and periapicalradiographs of abutmentteeth.A current and completeJustification of Need ForProsthesis Form, DC054(10/05) is required for priorauthorization.A benefit once in a five-yearperiod.A benefit when replacing apermanent anteriortooth/teeth and/or the archlacks posterior balancedocclusion. Lack of posteriorbalanced occlusion is definedas follows:a. five posterior permanentteeth are missing,(excluding 3rd molars), orb. all four 1st and 2ndpermanent molars aremissing, orc. the 1st and 2ndpermanent molars and

2nd bicuspid are missing

on the same side.Not a benefit for replacingmissing 3rd molars.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.Laboratory reline (D5761) isnot a benefit for thisprocedure.Chairside reline (D5741) is abenefit:a. once in a 12-monthperiod.b. six months after the dateof service for a partialdenture that requiredextractions, orc. 12 months after the dateof service for a partialdenture that did notrequire extractions.

Prior authorization isrequired.Radiographs for priorauthorization submitradiographs of all remainingnatural teeth and periapicalradiographs of abutmentteeth.A current and completeJustification of Need ForProsthesis Form, DC054(10/05) is required for priorauthorization.A benefit once in a five-yearperiod.A benefit when opposing afull denture and the arch lacksEffective June 1, 2014

Prosthodontic (Removable) Procedures (D5000-D5899)

6.7.

8.

9.

posterior balanced occlusion.

Lack of posterior balancedocclusion is defined asfollows:a. five posterior permanentteeth are missing,(excluding 3rd molars), orb. all four 1st and 2ndpermanent molars aremissing, orc. the 1st and 2ndpermanent molars and2nd bicuspid are missingon the same side.Not a benefit for replacingmissing 3rd molars.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.Laboratory reline (D5760) is abenefit:a. once in a 12-monthperiod.b. six months after the dateof service for a castpartial denture thatrequired extractions, orc. 12 months after the dateof service for a castpartial denture that didnot require extractions.Chairside reline (D5740) is abenefit:a. once in a 12 monthperiod.b. six months after the dateof service for a partialdenture that requiredextractions, orc. 12 months after the dateof service for a partialdenture that did notrequire extractions.

Effective June 1, 2014

PROCEDURE D5214

a.

MANDIBULAR PARTIAL DENTURE

Prior authorization isrequired.Radiographs for priorauthorization submitradiographs of all remainingnatural teeth and periapicalradiographs of abutmentteeth.A current and completeJustification of Need ForProsthesis Form, DC054(10/05) is required for priorauthorization.A benefit once in a five-yearperiod.A benefit when opposing afull denture and the arch lacksposterior balanced occlusion.Lack of posterior balancedocclusion is defined asfollows:a. five posterior permanentteeth are missing,(excluding 3rd molars), orb. all four 1st and 2ndpermanent molars aremissing, orc. the 1st and 2ndpermanent molars and2nd bicuspid are missingon the same side.Not a benefit for replacingmissing 3rd molars.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.Laboratory reline (D5761) is abenefit:

9.

once in a 12-monthperiod.b. six months after the dateof service for a castpartial denture thatrequired extractions, orc. 12 months after the dateof service for a castpartial denture that didnot require extractions.Chairside reline (D5741) is abenefit:a. once in a 12-monthperiod.b. six months after the dateof service for a partialdenture that requiredextractions, orc. 12 months after the dateof service for a partialdenture that did notrequire extractions.

Prosthodontic (Removable) Procedures (D5000-D5899)

PROCEDURE D5410

PROCEDURE D5411

ADJUST COMPLETE DENTURE MAXILLARY

ADJUST COMPLETE DENTURE

MANDIBULAR

1.

1.

2.

3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once per date of serviceper provider.b. twice in a 12-monthperiod per provider.Not a benefit:a. same date of service orwithin six months of thedate of service of acomplete denturemaxillary (D5110),immediate denturemaxillary (D5130)oroverdenture-complete(D5860).b. same date of service orwithin six months of thedate of service of a relinecomplete maxillarydenture (chairside)(D5730), reline completemaxillary denture(laboratory) (D5750) andtissue conditioning,maxillary (D5850).c. same date of service orwithin six months of thedate of service of repairbroken complete denturebase (D5510) and replacemissing or broken teethcomplete denture(D5520).

2.3.4.5.6.

7.

8.

PROCEDURE D5421

4.5.6.

7.

8.

PROCEDURE D5422ADJUST PARTIAL DENTURE MANDIBULAR1.

ADJUST PARTIAL DENTURE

MAXILLARY1.

Manual of CriteriaPage 5-54

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:once per date of service perprovider.twice in a 12-month periodper provider.Not a benefit:same date of service or withinsix months of the date ofservice of a completedenture- mandibular (D5120),immediate denturemandibular (D5140) oroverdenture-complete(D5860).same date of service or withinsix months of the date ofservice of a reline completemandibular denture(chairside) (D5731), relinecomplete mandibular denture(laboratory) (D5751) andtissue conditioning,mandibular (D5851).same date of service or withinsix months of the date ofservice of repair brokencomplete denture base(D5510) and replace missingor broken teeth-completedenture (D5520).

2.3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medical

Effective June 1, 2014

twice in a 12-month period

per provider.Not a benefit on the samedate of service as relinecomplete maxillary denture(chairside) (D5730), relinecomplete mandibular denture(chairside) (D5731), relinecomplete maxillary denture(laboratory) (D5750) andreline complete mandibulardenture (laboratory) (D5751).All adjustments made for sixmonths after the date ofrepair, by the same providerand same arch, are includedin the fee for this procedure.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires an arch code.A benefit:a. up to a maximum of four,per arch, per date ofservice per provider.b. twice per arch, in a12month period perprovider.All adjustments made for sixmonths after the date ofrepair, by the same providerand same arch, are includedin the fee for this procedure.

PROCEDURE D5610

5.

necessity is not required for

payment.Requires an arch code.A benefit:a. once per arch, per date ofservice per provider.b. twice per arch, in a 12month period perprovider.c. for partial dentures only.Not a benefit same date ofservice as reline maxillarypartial denture (chairside)(D5740), reline mandibularpartial denture (chairside)(D5741), reline maxillarypartial denture (laboratory)(D5760) and relinemandibular partial denture(laboratory) (D5761).All adjustments made for sixmonths after the date ofrepair, by the same providerand same arch, are includedin the fee for this procedure.

PROCEDURE D5620REPAIR CAST FRAMEWORK1.2.3.

4.

Requires a laboratory invoice

for payment.Requires an arch code.A benefit:a. once per arch, per date ofservice per provider.b. twice per arch, in a 12month period perprovider.All adjustments made for sixmonths after the date ofrepair, by the same providerand same arch, are includedin the fee for this procedure.

REPAIR RESIN DENTURE BASE

1.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalManual of CriteriaPage 5-55

Prosthodontic (Removable) Procedures (D5000-D5899)

PROCEDURE D5630

PROCEDURE D5650

PROCEDURE D5670

REPAIR OR REPLACE BROKEN

CLASP

ADD TOOTH TO EXISTING

PARTIAL DENTURE

1.

1.

REPLACE ALL TEETH AND ACRYLIC

ON CAST METAL FRAMEWORK(MAXILLARY)

2.3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires an arch code.A benefit:a. up to a maximum ofthree, per date of serviceper provider.b. twice per arch, in a 12month period perprovider.All adjustments made for sixmonths after the date ofrepair, by the same providerand same arch, are includedin the fee for this procedure.

2.3.

4.5.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpaymentRequires a tooth code.A benefit:a. for up to a maximum ofthree, per date of serviceper provider.b. once per tooth.Not a benefit for adding 3rdmolars.All adjustments made for sixmonths after the date ofrepair, by the same providerand same arch, are includedin the fee for this procedure.

PROCEDURE D5640

PROCEDURE D5660

REPLACE BROKEN TEETH PER

TOOTH

ADD CLASP TO EXISTING PARTIAL

DENTURE

1.

1.

2.3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires an arch code.A benefit:a. up to a maximum of four,per arch, per date ofservice per provider.b. twice per arch, in a 12month period perprovider.c. for partial dentures only.All adjustments made for sixmonths after the date ofrepair, by the same providerand same arch, are includedin the fee for this procedure.

2.3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpaymentRequires an arch code.A benefit:a. for up to a maximum ofthree, per date of serviceper provider.b. twice per arch, in a 12month period perprovider.All adjustments made for sixmonths after the date ofrepair, by the same providerand same arch, are includedin the fee for this procedure.

This procedure is not a

benefit.

PROCEDURE D5671REPLACE ALL TEETH AND ACRYLICON CAST METAL FRAMEWORK(MANDIBULAR)This procedure is not abenefit.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:Effective June 1, 2014

Prosthodontic (Removable) Procedures (D5000-D5899)

a.

3.

4.

once in a 12-monthperiod.b. six months after the dateof service for aimmediate denturemaxillary (D5130) orimmediate overdenturecomplete (D5860) thatrequired extractions, orc. 12 months after the dateof service for a complete(remote) denturemaxillary (D5110) oroverdenture (remote)complete (D5860) thatdid not requireextractions.Not a benefit within 12months of a reline completemaxillary denture (laboratory)(D5750).All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.

3.

4.

RELINE MAXILLARY PARTIAL

DENTURE (CHAIRSIDE)1.

2.

RELINE COMPLETE MANDIBULAR

DENTURE (CHAIRSIDE)

2.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once in a 12-monthperiod.b. six months after the dateof service for aimmediate denturemandibular (D5140) orimmediate overdenturecomplete (D5860) thatrequired extractions, orc. 12 months after the dateof service for a complete

Effective June 1, 2014

4.

3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once in a 12-monthperiod.b. six months after the dateof service for maxillarypartial denture- resinbase (D5211) or maxillarypartial denture- castmetal framework withresin denture bases(D5213) that requiredextractions, orc. 12 months after the dateof service for maxillarypartial denture- resinbase (D5211) or maxillarypartial denture- castmetal framework withresin denture bases(D5213) that did notrequire extractions.Not a benefit within 12months of a reline maxillary

partial denture (laboratory)

(D5760).All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.

PROCEDURE D5741RELINE MANDIBULAR PARTIALDENTURE (CHAIRSIDE)1.

PROCEDURE D5740

PROCEDURE D5731

1.

(remote) denturemandibular (D5120) or

overdenture (remote)complete (D5860) thatdid not requireextractions.Not a benefit within 12months of a reline completemandibular denture(laboratory) (D5751).All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.

2.

3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once in a 12-monthperiod.b. six months after the dateof service for mandibularpartial denture- resinbase (D5212) ormandibular partialdenture- cast metalframework with resindenture bases (D5214)that required extractions,orc. 12 months after the dateof service for mandibularpartial denture- resinbase (D5212) ormandibular partialdenture- cast metalframework with resindenture bases (D5214)that did not requireextractions.Not a benefit within 12months of a reline mandibularpartial denture (laboratory)(D5761).All adjustments made for sixmonths after the date ofservice, by the same provider,Manual of CriteriaPage 5-57

Prosthodontic (Removable) Procedures (D5000-D5899)

are included in the fee for thisprocedure.

PROCEDURE D5750

2.

RELINE COMPLETE MAXILLARY

DENTURE (LABORATORY)1.

2.

3.

4.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once in a 12-monthperiod.b. six months after the dateof service for aimmediate denturemaxillary (D5130) orimmediate overdenturecomplete (D5860) thatrequired extractions, orc. 12 months after the dateof service for a complete(remote) denturemaxillary (D5110) oroverdenture (remote)complete (D5860) thatdid not requireextractions.Not a benefit within 12months of a reline completemaxillary denture (chairside)(D5730).All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.

PROCEDURE D5751RELINE COMPLETE MANDIBULARDENTURE (LABORATORY)1.

Submission of radiographs,photographs or writtendocumentationdemonstrating medical

Manual of CriteriaPage 5-58

3.

4.

necessity is not required for

payment.A benefit:a. once in a 12-monthperiod.b. six months after the dateof service for aimmediate denturemandibular (D5140) orimmediate overdenturecomplete (D5860) thatrequired extractions, orc. 12 months after the dateof service for a complete(remote) denture mandibular (D5120) oroverdenture (remote) complete (D5860) thatdid not requireextractions.Not a benefit within 12months of a reline completemandibular denture(chairside) (D5731).All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.

3.

4.

PROCEDURE D5761RELINE MANDIBULAR PARTIALDENTURE (LABORATORY)1.

PROCEDURE D5760RELINE MAXILLARY PARTIALDENTURE (LABORATORY)1.

2.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once in a 12-monthperiod.b. six months after the dateof service for maxillarypartial denture- castmetal framework withresin denture bases

(D5213) that required

extractions, orc. 12 months after the dateof service for maxillarypartial denture- castmetal framework withresin denture bases(D5213) that did notrequire extractions.Not a benefit:a. within 12 months of areline maxillary partialdenture (chairside)(D5740).b. for a maxillary partialdenture- resin base(D5211).All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.

2.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit:a. once in a 12-monthperiod.b. six months after the dateof service for mandibularpartial denture- castmetal framework withresin denture bases(D5214) that requiredextractions, orc. 12 months after the dateof service for mandibularpartial denture- castmetal framework withresin denture basesEffective June 1, 2014

Prosthodontic (Removable) Procedures (D5000-D5899)

3.

4.

(D5214) that did not

require extractions.Not a benefit:a. within 12 months of areline mandibular partialdenture (chairside)(D5741).b. for a mandibular partialdenture- resin base(D5212).All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.

Effective June 1, 2014

A benefit twice per prosthesis

in a 36-month period.Not a benefit:a. same date of service asreline complete maxillarydenture (chairside)(D5730), reline maxillarypartial denture(chairside) (D5740), relinecomplete maxillarydenture (laboratory)(D5750) and relinemaxillary partial denture(laboratory) (D5760).b. same date of service as aprosthesis that did notrequire extractions.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.Tissue conditioning isdesigned to heal unhealthyridges prior to a moredefinitive treatment.

2.3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.A benefit twice per prosthesisin a 36-month period.Not a benefit:a. same date of service asreline completemandibular denture(chairside) (D5731), relinemandibular partialdenture (chairside)(D5741), reline completemandibular denture(laboratory) (D5751) and

4.

5.

reline mandibular partial

denture (laboratory)(D5761).b. same date of service as aprosthesis that did notrequire extractions.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.Tissue conditioning isdesigned to heal unhealthyridges prior to a moredefinitive treatment.

PROCEDURE D5860OVERDENTURE COMPLETE, BYREPORT1.2.

3.

4.5.6.

Prior authorization isrequired.Radiographs for priorauthorization submit allradiographs of remainingnatural teeth includingperiapical radiographs ofteeth to be retained.A current and completeJustification of Need ForProsthesis Form, DC054(10/05) is required, thatincludes which teeth are to beretained, for priorauthorization.Requires an arch code.A benefit once in a five-yearperiod.Complete denture laboratoryrelines (D5750 and D5751)are a benefit:a. six months after the dateof service for animmediate overdenturethat required extractions,orb. 12 months after the dateof service for a completeManual of CriteriaPage 5-59

Prosthodontic (Removable) Procedures (D5000-D5899)

7.

8.

9.

overdenture that did not

require extractions.Complete denture chairsiderelines (D5730 and D5731)are a benefit:a. six months after the dateof service for animmediate overdenturethat required extractions,orb. 12 months after the dateof service for a completeoverdenture that did notrequire extractions.All adjustments made for sixmonths after the date ofservice, by the same provider,are included in the fee for thisprocedure.Teeth to be retained are noteligible for preventative,periodontal, endodontic orrestorative procedures. Onlyextractions for the retainedteeth shall be a benefit.

PROCEDURE D5875MODIFICATION OF REMOVABLEPROSTHESIS FOLLOWINGIMPLANT SURGERY.This procedure is not abenefit.

Prior authorization is required

for non-emergencyprocedures.Radiographs for priorauthorization or payment submit radiographs ifapplicable for the type ofprocedure.Photographs for priorauthorization or payment submit photographs ifapplicable for the type ofprocedure.Submit a current andcomplete Justification ofNeed For Prosthesis Form,DC054 (10/05), if applicablefor the type of procedure, forprior authorization.Written documentation forprior authorization orpayment describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity, anypertinent history and theproposed or actual treatment.Procedure D5899 shall beused:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patienthas an exceptionalEffective June 1, 2014

Maxillofacial Prosthetics General Policies (D5900-D5999)

Maxillofacial Prosthetics General Policies (D5900-D5999)

1.

2.3.

4.

Maxillofacial prosthetic services are for the anatomic and functional reconstruction of those regions of themaxilla and mandible and associated structures that are missing or defective because of surgical intervention,trauma (other than simple or compound fractures), pathology, developmental or congenital malformations.All maxillofacial prosthetic procedures require written documentation for payment or prior authorization.Refer to the individual procedures for specific requirements.Prior authorization is required for the following procedures:A) trismus appliance (D5937),B) palatal lift prosthesis, interim (D5958),C) fluoride gel carrier (D5986),D) surgical splint (D5988).All maxillofacial prosthetic procedures include routine postoperative care, revisions and adjustments for 90days after the date of delivery.

Effective June 1, 2014

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Maxillofacial Prosthetics General Policies (D5900-D5999)

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Manual of CriteriaPage 5-62

Effective June 1, 2014

Maxillofacial Prosthetic Procedures (D5900-D5999)

Maxillofacial Prosthetic Procedures (D5900-D5999)

PROCEDURE D5911

b.

FACIAL MOULAGE (SECTIONAL)

1.

Written documentation for

payment - shall include:a. the etiology of thedisease and/or condition,andb. a description of theassociated surgery or anoperative report, andc. a description of theprosthesis.

1.

Written documentation for

payment - shall include:a. the etiology of thedisease and/or condition,andb. a description of theassociated surgery or anoperative report, andc. a description of theprosthesis.

ORBITAL PROSTHESIS1.

1.

PROCEDURE D5914AURICULAR PROSTHESIS1.

Written documentation for

Effective June 1, 2014

Written documentation for

payment - shall include:a. the etiology of thedisease and/or condition,andb. a description of theassociated surgery or anoperative report.c. Not a benefit on thesame date of service asocular prosthesis, interim(D5923).

Written documentation for

payment - shall include:a. the etiology of thedisease and/or condition,andb. a description of theassociated surgery or anoperative report.c. Not a benefit on thesame date of service withan ocular prosthesis(D5916).

Written documentation for

payment - shall include:a. the etiology of thedisease and/or condition,andb. a description of theassociated surgery or anoperative report, andc. a description of theprosthesis.

Manual of CriteriaPage 5-64

Written documentation for

payment - shall include:a. the etiology of thedisease and/or condition,andb. a description of theassociated surgery or anoperative report, andc. a description of theprosthesis.Not a benefit on the samedate of service as obturatorprosthesis, surgical (D5931)and obturator prosthesis,interim (D5936).

PROCEDURE D5933OBTURATOR PROSTHESIS,MODIFICATION1.

2.3.

OBTURATOR PROSTHESIS,SURGICAL1.

c.

OBTURATOR PROSTHESIS,DEFINITIVE

AURICULAR PROSTHESIS,REPLACEMENT

ORBITAL PROSTHESIS,REPLACEMENT

b.

PROCEDURE D5932

PROCEDURE D5927

PROCEDURE D5928

a.

Not a benefit on the same

date of service as obturatorprosthesis, definitive (D5932)and obturator prosthesis,interim (D5936).

Written documentation for

payment - shall include themedical necessity for themodification.A benefit twice in a 12 monthperiod.Not a benefit on the samedate of service as obturatorprosthesis, surgical (D5931),obturator prosthesis,definitive (D5932) andobturator prosthesis, interim(D5936).

PROCEDURE D5935MANDIBULAR RESECTIONPROSTHESIS WITHOUT GUIDEFLANGE1.

1.

Written documentation for

payment - shall include:

Written documentation for

payment - shall include:a. the etiology of thedisease and/or condition,andb. a description of theassociated surgery or anoperative report, andc. a description of theprosthesis.

PROCEDURE D5936OBTURATOR PROSTHESIS,INTERIM1.

2.

PROCEDURE D5934MANDIBULAR RESECTIONPROSTHESIS WITH GUIDE FLANGE

the etiology of the

Written documentation for

payment - shall include:a. the etiology of thedisease and/or condition,andb. a description of theassociated surgery or anoperative report, andc. a description of theprosthesis.Not a benefit on the samedate of service as obturatorprosthesis, surgical (D5931)and obturator prosthesis,definitive (D5932).

Written documentation for

Written documentation for

payment - shall include thetreatment performed.A benefit for patients underthe age of 18.

2.

Not a benefit on the same

date of service as palatal liftprosthesis, interim (D5958).'

PALATAL LIFT PROSTHESIS,

INTERIM1.2.

3.

Prior authorization isrequired.Written documentation forprior authorization - shallinclude the treatment to beperformed.Not a benefit on the samedate of service with palatal liftprosthesis, definitive (D5955).

Written documentation for

Effective June 1, 2014

Written documentation for

payment - shall include thetreatment performed.A benefit for patients underthe age of 18.

PROCEDURE D5982

Written documentation for

payment - shall include thetreatment performed.A benefit twice in a 12-monthperiod.Not a benefit on the samedate of service as palatal liftprosthesis, definitive (D5955)and palatal lift prosthesis,interim (D5958).

PROCEDURE D5960SPEECH AID PROSTHESIS,MODIFICATION1.

2.3.

Written documentation for

payment - shall include thetreatment performed.A benefit twice in a 12-monthperiod.Not a benefit on the samedate of service as speech aidprosthesis, pediatric (D5952)and speech aid prosthesis,adult (D5953).

PROCEDURE D5983RADIATION CARRIER1.

2.

Written documentation for

payment - shall include theetiology of the disease and/orcondition.Requires an arch code.

Written documentation for

PROCEDURE D5993MAINTENANCE AND CLEANINGOF A MAXILLOFACIALPROSTHESIS (EXTRA ORINTRAORAL) OTHER THANREQUIRED ADJUSTMENTS, BYREPORTThis procedure is not abenefit.

Manual of CriteriaPage 5-66

5.

Prior authorization is required

for non-emergencyprocedures.Radiographs for priorauthorization or payment submit radiographs ifapplicable for the type ofprocedure.Photographs for priorauthorization or payment submit photographs ifapplicable for the type ofprocedure.Written documentation oroperative report for priorauthorization or payment shall describe the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the proposed oractual treatment.Procedure D5999 shall beused:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patienthas an exceptionalmedical condition tojustify the medicalnecessity.Documentation shallinclude the medicalcondition and the specificCDT code associated withthe treatment.

Effective June 1, 2014

Implant Services General Policies (D6000-D6199)

Implant Services General Policies (D6000-D6199)

1.

2.

3.4.

Implant services are a benefit only when exceptional medical conditions are documented and shall bereviewed by the Medi-Cal Dental Program for medical necessity for prior authorization. Exceptional medicalconditions include, but are not limited to:A) cancer of the oral cavity requiring ablative surgery and/or radiation leading to destruction of alveolarbone, where the remaining osseous structures are unable to support conventional dental prostheses.B) severe atrophy of the mandible and/or maxilla that cannot be corrected with vestibular extensionprocedures or osseous augmentation procedures, and the patient is unable to function with conventionalprostheses.C) skeletal deformities that preclude the use of conventional prostheses (such as arthrogryposis, ectodermaldysplasia, partial anaodontia and cleidocranial dysplasia).D) traumatic destruction of jaw, face or head where the remaining osseous structures are unable to supportconventional dental prostheses.Providers shall submit complete case documentation (such as radiographs, scans, operative reports,craniofacial panel reports, diagnostic casts, intraoral/extraoral photographs and tracings) necessary todemonstrate the medical necessity of the requested implant services.Single tooth implants are not a benefit of the Medi-Cal Dental Program.Implant removal, by report (D6100) is a benefit. Refer to the procedure for specific requirements.

Effective June 1, 2014

Manual of CriteriaPage 5-67

Implant Services General Policies (D6000-D6199)

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Effective June 1, 2014

Implant Service Procedures (D6000-D6199)

Implant Service Procedures (D6000-D6199)

PROCEDURE D6010

PROCEDURE D6051

PROCEDURE D6058

SURGICAL PLACEMENT OFIMPLANT BODY: ENDOSTEALIMPLANT

INTERIM ABUTMENT

ABUTMENT SUPPORTEDPORCELAIN/CERAMIC CROWN

1.

2.3.

4.

5.

6.

Implant services are a benefit

only when exceptionalmedical conditions aredocumented and shall bereviewed for medicalnecessity. Refer to ImplantServices General policies forspecific requirements.Prior authorization isrequired.Radiographs for priorauthorization - submit arch,pre-operative periapicaland/or panoramicradiographs as applicable.Photographs for priorauthorization - submit asapplicable.Written documentation forprior authorization shalldescribe the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the proposedtreatment.Requires a tooth or arch code,as applicable for the type ofprocedure.

IMPLANT SUPPORTED RETAINER

See the criteria for Procedure

See the criteria for Procedure

PROCEDURE D6090REPAIR IMPLANT SUPPORTEDPROSTHESIS, BY REPORTSee the criteria for ProcedureD6010.

PROCEDURE D6075

PROCEDURE D6069

See the criteria for Procedure

D6010.

See the criteria for Procedure

D6010.

See the criteria for Procedure

D6010.

PROCEDURE D6091REPLACEMENT OF SEMIPRECISION OR PRECISIONATTACHMENT (MALE OR FEMALECOMPONENT) OFIMPLANT/ABUTMENTSUPPORTED PROSTHESIS, PERATTACHMENTSee the criteria for ProcedureD6010.

PROCEDURE D6092RECEMENT IMPLANT/ABUTMENTSUPPORTED CROWN1.2.

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtenEffective June 1, 2014

Implant Service Procedures (D6000-D6199)

3.4.

5.

documentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.The original provider isresponsible for all recementations within the first12 months following theinitial placement ofimplant/abutment supportedcrowns.Not a benefit within 12months of a previous recementation by the sameprovider.

PROCEDURE D6095

PROCEDURE D6103

REPAIR IMPLANT ABUTMENT, BY

REPORT

BONE GRAFT FOR REPAIR OF

PERIIMPLANT DEFECT - NOTINCLUDING FLAP ENTRY ANDCLOSURE OR, WHEN INDICATED,PLACEMENT OF A BARRIERMEMBRANE OR BIOLOGICMATERIALS TO AID IN OSSEOUSREGENERATION

See the criteria for Procedure

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a quadrant code.The original provider isresponsible for all recementations within the first12 months following theinitial placement ofimplant/abutment supportedfixed partial dentures.Not a benefit within 12months of a previous recementation by the sameprovider.

Implant Service Procedures (D6000-D6199)

4.

5.

6.

Photographs for prior

authorization - submit asapplicable for the type ofprocedure.Written documentation forprior authorization shalldescribe the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the proposedtreatment.Requires a tooth or arch code,as applicable for the type ofprocedure.

Manual of CriteriaPage 5-72

Effective June 1, 2014

Fixed Prosthodontic General Policies (D6200-D6999)

Fixed Prosthodontic General Policies (D6200-D6999)

1.

2.

3.

4.

5.6.7.8.9.

10.

11.

12.13.14.

Fixed partial dentures (bridgework) are considered beyond the scope of the Medi-Cal Dental Program.However, the fabrication of a fixed partial denture shall be considered for prior authorization only whenmedical conditions or employment preclude the use of a removable partial denture. Most importantly, thepatient shall first meet the criteria for a removable partial denture before a fixed partial denture will beconsidered.Medical conditions, which preclude the use of a removable partial denture, include:A) the epileptic patient where a removable partial denture could be injurious to their health during anuncontrolled seizure,B) the paraplegia patient who utilizes a mouth wand to function to any degree and where a mouth wand isinoperative because of missing natural teeth,C) patients with neurological disorders whose manual dexterity precludes proper care and maintenance of aremovable partial denture.Documentation for medical conditions shall be submitted for prior authorization that includes a written,signed and dated statement from the patients physician, on their professional letterhead, describing thepatients medical condition and the reason why a removable partial denture would be injurious to thepatients health.Documentation for obtaining employment shall be submitted for prior authorization that includes a writtenstatement from the patients case manager or eligibility worker stating why the nature of the employmentprecludes the use of a removable partial denture.Fixed partial dentures are a benefit once in a five-year period only on permanent teeth when the abovecriteria are met.Current periapical radiographs of the retainer (abutment) teeth and arch radiographs are required for priorauthorization.Fixed partial dentures are not a benefit when the prognosis of the retainer (abutment) teeth is questionabledue to non-restorability or periodontal involvement.Posterior fixed partial dentures are not a benefit when the number of missing teeth requested to be replacedin the quadrant does not significantly impact the patients masticatory ability.Tooth and soft tissue preparation, crown lengthening, cement bases, direct and indirect pulp capping,amalgam or acrylic buildups, pins (D2951), bonding agents, lining agents, impressions, temporary crowns,adjustments (D9951), polishing, local anesthesia (D9210) and any other associated procedures are included inthe fee for a completed fixed partial denture.Arch integrity and overall condition of the mouth, including the patients ability to maintain oral health, shallbe considered for prior authorization. Prior authorization shall be based upon a supportable five-yearprognosis for the fixed partial denture retainer (abutment).Fixed partial denture retainers (abutments) on root canal treated teeth shall be considered only aftersatisfactory completion of root canal therapy. Post root canal treatment periapical and arch radiographs shallbe submitted for prior authorization of fixed partial dentures.Partial payment will not be made for an undelivered fixed partial denture. Payment will be made only uponfinal cementation.Fixed partial denture inlay/onlay retainers (abutments) (D6545-D6634) are not a benefit.Cast resin bonded fixed partial dentures (Maryland Bridges) are not a benefit.

Effective June 1, 2014

Manual of CriteriaPage 5-73

Fixed Prosthodontic Policies (D6200-D6999)

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Effective June 1, 2014

Fixed Prosthodontic Procedures (D6200-D6999)

Fixed Prosthodontic Procedures (D6200-D6999)

PROCEDURE D6205

PROCEDURE D6212

PONTIC INDIRECT RESIN BASED

COMPOSITE

PONTIC CAST NOBLE METAL

This procedure is not a

benefit.

PROCEDURE D6210

This procedure is not a

benefit.

PROCEDURE D6214

PROCEDURE D6211

This procedure is not a

benefit.

PROCEDURE D6240PONTIC PORCELAIN FUSED TOHIGH NOBLE METAL

PONTIC CAST PREDOMINANTLY

BASE METAL1.2.

3.

4.5.

6.

Prior authorization isrequired.Radiographs for priorauthorization submit archand periapical radiographs.Written documentation forprior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).c. only when billed on thesame date of service withfixed partial dentureretainers (abutments)(D6721, D6740, D6751,D6781, D6783 andD6791).Not a benefit for patientsunder the age of 13.

Effective June 1, 2014

This procedure is not a

benefit.

PROCEDURE D6241PONTIC PORCELAIN FUSED TOPREDOMINANTLY BASE METAL1.2.

3.

4.5.

Prior authorization isrequired.Radiographs for priorauthorization submit archand periapical radiographs.Written documentation forprior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).c. only when billed on thesame date of service withfixed partial dentureretainers (abutments)(D6721, D6740, D6751,D6781, D6783 andD6791).

Not a benefit for patients

under the age of 13.

PROCEDURE D6242PONTIC PORCELAIN FUSED TONOBLE METAL

PONTIC TITANIUM

PONTIC CAST HIGH NOBLE

METALThis procedure is not abenefit.

6.

This procedure is not a

benefit.

PROCEDURE D6245PONTIC PORCELAIN/CERAMIC1.2.

3.

4.5.

6.

Prior authorization isrequired.Radiographs for priorauthorization submit archand periapical radiographs.Written documentation forprior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).c. only when billed on thesame date of service withfixed partial dentureretainers (abutments)(D6721, D6740, D6751,D6781, D6783 andD6791).Not a benefit for patientsunder the age of 13.

PROCEDURE D6250PONTIC RESIN WITH HIGHNOBLE METALThis procedure is not abenefit.Manual of CriteriaPage 5-75

Fixed Prosthodontic Procedures (D6200-D6999)

PROCEDURE D6251

PROCEDURE D6545

PROCEDURE D6605

PONTIC RESIN WITH

PREDOMINANTLY BASE METAL

RETAINER CAST METAL FOR

RESIN BONDED FIXEDPROSTHESIS

INLAY CAST PREDOMINANTLY

BASE METAL, THREE OR MORESURFACES

1.2.

3.

4.5.

6.

Prior authorization isrequired.Radiographs for priorauthorization submit archand periapical radiographs.Written documentation forprior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).c. only when billed on thesame date of service withfixed partial dentureretainers (abutments)(D6721, D6740, D6751,D6781, D6783 andD6791).Not a benefit for patientsunder the age of 13.

PROCEDURE D6252PONTIC RESIN WITH NOBLEMETALThis procedure is not abenefit.

Fixed Prosthodontic Procedures (D6200-D6999)

ONLAY CAST PREDOMINANTLY

This procedure is not a

benefit.

PROCEDURE D6615ONLAY CAST NOBLE METAL,THREE OR MORE SURFACESThis procedure is not abenefit.

PROCEDURE D6624INLAY- TITANIUM

6.

Written documentation for

prior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).Not a benefit for patientsunder the age of 13.

This procedure is not a

benefit.

PROCEDURE D6740

ONLAY- TITANIUM

CROWN PORCELAIN/CERAMIC

CROWN- INDIRECT RESIN BASED

COMPOSITEThis procedure is not abenefit.

1.2.

3.

PROCEDURE D6720CROWN RESIN WITH HIGHNOBLE METALThis procedure is not abenefit.

Effective June 1, 2014

This procedure is not a

CROWN RESIN WITH NOBLE

METAL

PROCEDURE D6634

PROCEDURE D6710

CROWN PORCELAIN FUSED TO

HIGH NOBLE METAL

PROCEDURE D6722

This procedure is not a

benefit.

This procedure is not a

benefit.

PROCEDURE D6750

6.

Prior authorization isrequired.Radiographs for priorauthorization submit archand periapical radiographs.Written documentation forprior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).Not a benefit for patientsunder the age of 13.

4.5.

6.

Prior authorization isrequired.Radiographs for priorauthorization submit archand periapical radiographs.Written documentation forprior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).Not a benefit for patientsunder the age of 13.

PROCEDURE D6780CROWN CAST HIGH NOBLEMETALThis procedure is not abenefit.

Manual of CriteriaPage 5-77

Fixed Prosthodontic Procedures (D6200-D6999)

PROCEDURE D6781

a.b.

CROWN CASTPREDOMINANTLY BASE METAL1.2.

3.

4.5.

6.

Prior authorization isrequired.Radiographs for priorauthorization submit archand periapical radiographs.Written documentation forprior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).Not a benefit for patientsunder the age of 13.

6.

PROCEDURE D6790CROWN FULL CAST HIGH NOBLEMETALThis procedure is not abenefit.

once in a five year period.

only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).Not a benefit for patientsunder the age of 13.

6.

Prior authorization isrequired.Radiographs for priorauthorization submit archand periapical radiographs.Written documentation forprior authorization- shall besubmitted for employment ormedical reasons. Refer toFixed Prosthodontic GeneralPolicies for specificrequirements.Requires a tooth code.A benefit:a. once in a five year period.b. only when the criteria aremet for a resin partialdenture or cast partialdenture (D5211, D5212,D5213 and D5214).Not a benefit for patientsunder the age of 13.

PROCEDURE D6792CROWN FULL CAST NOBLEMETALThis procedure is not abenefit.

PROCEDURE D6793PROVISIONAL RETAINER CROWN- FURTHER TREATMENT ORCOMPLETION OF DIAGNOSISNECESSARY PRIOR TO FINALIMPRESSIONThis procedure is not abenefit.

PROCEDURE D6794CROWN- TITANIUMThis procedure is not abenefit.

PROCEDURE D6920CONNECTOR BARThis procedure is not abenefit.

PROCEDURE D6930RECEMENT FIXED PARTIALDENTURE1.2.

3.4.

5.

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a quadrant code.The original provider isresponsible for all recementations within the first12 months following theinitial placement of a fixedpartial denture.Not a benefit within 12months of a previous recementation by the sameprovider.

Effective June 1, 2014

1.2.

3.

4.

5.6.

7.

Prior authorization isrequired.Radiographs for priorauthorization submitperiapical radiographs.Photographs for priorauthorization submitphotographs if applicable forthe type of procedure.Written documentation forprior authorization describethe specific conditions to beaddressed by the procedure,the rationale demonstratingthe medical necessity, anypertinent history and theproposed treatment.Requires a tooth code.Not a benefit within 12months of initial placement,same provider.Procedure D6999 shall beused:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patienthas an exceptionalmedical condition tojustify the medicalnecessity.Documentation shallinclude the medicalcondition and the specificCDT code associated withthe treatment.

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Fixed Prosthodontic Procedures (D6200-D6999)

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Effective June 1, 2014

Oral and Maxillofacial Surgery General Policies (D7000-D7999)

Oral and Maxillofacial Surgery General Policies (D7000-D7999)

1.2.

3.4.

5.

6.

Diagnostic pre-operative radiographs are required for all hard tissue surgical procedures that are submittedfor prior authorization and/or payment. Refer to the individual procedure for specific requirements.Local anesthetic, sutures and routine postoperative care within 30 days following an extraction procedure(D7111-D7250) are considered part of, and included in, the fee for the procedure. All other oral andmaxillofacial surgery procedures include routine postoperative care for 90 days.The level of payment for multiple surgical procedures performed on the same date of service shall be modifiedto the most inclusive procedure.Extractions (D7111-D7250):A) The following conditions shall be considered medically necessary and shall be a benefit:i) full bony impacted supernumerary teeth or mesiodens that interfere with the alignment of otherteeth,ii) teeth which are involved with a cyst, tumor or other neoplasm,iii) unerupted teeth which are severely distorting the normal alignment of erupted teeth or causing theresorption of the roots of other teeth,iv) the extraction of all remaining teeth in preparation for a full prosthesis,v) extraction of third molars that are causing repeated or chronic pericoronitisvi) extraction of primary teeth required to minimize malocclusion or malalignment when there isadequate space to allow normal eruption of succedaneous teeth,vii) perceptible radiologic pathology that fails to elicit symptoms,viii) extractions that are required to complete orthodontic dental services excluding prophylactic removalof third molars,ix) when the prognosis of the tooth is questionable due to non-restorability or periodontal involvement.B) The prophylactic extraction of 3rd molars is not a benefit.C) The fee for surgical extractions includes the removal of bone and/or sectioning of tooth, and elevation ofmucoperiosteal flap, if indicated.D) Classification of surgical extractions and impactions shall be based on the anatomical position of the toothrather than the surgical technique employed in the removal.E) The level of payment for surgical extractions shall be allowed or modified based on the degree of difficultyas evidenced by the diagnostic radiographs. When radiographs do not accurately depict the degree ofdifficulty, written documentation and/or photographs shall be considered.Fractures (D7610-D7780):A) The placement and removal of wires, bands or splints is included in the fee for the associated procedure.B) Routine postoperative care within 90 days is included in the fee for the associated procedure.C) When extensive multiple or bilateral procedures are performed at the same operative session, eachprocedure shall be valued as follows:i) 100% (full value) for the first or major procedure, andii) 50% for the second procedure, andiii) 25% for the third procedure, andiv) 10% for the fourth procedure, andv) 5% for the fifth procedure, andvi) over five procedures, by report.D) Assistant surgeons are paid 20% of the surgical fee allowed to the surgeon. Hospital call (D9420) is notpayable to assistant surgeons.Temporomandibular Joint Dysfunctions (D7810-D7899):

Effective June 1, 2014

Manual of CriteriaPage 5-81

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

7.

A) TMJ dysfunction procedures are limited to differential diagnosis and symptomatic care. Not included as abenefit are those TMJ treatment modalities that involve prosthodontia, orthodontia and full or partialocclusal rehabilitation.B) Most TMJ dysfunction procedures require prior authorization. Submission of sufficient diagnosticinformation to establish the presence of the dysfunction is required. Refer to the individual proceduresfor specific submission requirements.C) TMJ dysfunction procedures solely for the treatment of bruxism is not a benefit.Repair Procedures (D7910-D7998):A) Suture procedures (D7910, D7911 and D7912) are not a benefit for the closure of surgical incisions.

Manual of CriteriaPage 5-82

Effective June 1, 2014

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

PROCEDURE D7111EXTRACTION, CORONALREMNANTS DECIDUOUS TOOTH1.

2.3.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.Not a benefit forasymptomatic teeth.

alveolar bone or sectioning of

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a tooth code.Not a benefit to the sameprovider who performed theinitial tooth extraction.

REMOVAL OF IMPACTED TOOTH

SURGICAL REMOVAL OF ERUPTED

Radiographs for payment

submit a current, diagnosticpreoperative periapical orpanoramic radiographdepicting the entire tooth.Requires a tooth code.A benefit when the removalof any erupted tooth requiresthe elevation of amucoperiosteal flap and theremoval of substantial

Effective June 1, 2014

Radiographs for payment

submit a current, diagnosticpreoperative periapical orpanoramic radiographdepicting the entire tooth.Requires a tooth code.A benefit when the majorportion or the entire occlusalsurface is covered bymucogingival soft tissue.

Radiographs for payment

submit a current, diagnosticpreoperative periapical orpanoramic radiographdepicting the entire tooth.Requires a tooth code.A benefit when the removalof any impacted toothrequires the elevation of amucoperiosteal flap and theremoval of substantialalveolar bone. One of theproximal heights of contour ofthe crown shall be covered bybone.

ORAL ANTRAL FISTULA CLOSURE

Radiographs for payment submit a current, diagnostic

preoperative radiograph.Written documentation oroperative report for payment shall describe the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.Requires a quadrant code.A benefit for the excision of afistulous tract between themaxillary sinus and oralcavity.Not a benefit in conjunctionwith extraction procedures(D7111 D7250).

Radiographs for payment

submit a preoperativeperiapical radiograph.Written documentation forpayment shall describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity, anypertinent history and thetooth/teeth reimplanted.Requires an arch code.A benefit:a. once per arch regardlessof the number of teethinvolved, andb. for permanent anteriorteeth only.The fee for this procedureincludes splinting and/orstabilization, postoperativecare and the removal of thesplint or stabilization, by thesame provider.

PROCEDURE D7272TOOTH TRANSPLANTATION(INCLUDES REIMPLANTATIONFROM ONE SITE TO ANOTHERAND SPLINTING AND/ORSTABILIZATION)This procedure is not abenefit.

PROCEDURE D7280SURGICAL ACCESS OF ANUNERUPTED TOOTH1.2.

3.

4.5.

Prior authorization isrequired.Radiographs for priorauthorization submit a preoperative radiographdepicting the impacted tooth.Written documentation forprior authorization shalldescribe the specificconditions addressed by theprocedure and the rationaledemonstrating the medicalnecessity.Requires a tooth code.Not a benefit:a. for patients age 21 orolder.b. for 3rd molars.

PROCEDURE D7282MOBILIZATION OF ERUPTED ORMALPOSITIONED TOOTH TO AIDERUPTIONThis procedure is not abenefit.

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

for patients age 21 years

surgery (D3410-D3426), anextraction (D7111-D7250) andan excision of any soft tissuesor intraosseous lesions(D7410-D7461) in the samearea or region on the samedate of service.

PROCEDURE D7285BIOPSY OF ORAL TISSUE HARD(BONE, TOOTH)1.

2.

3.4.

5.

Radiographs for payment

submit a pre-operativeradiograph.A pathology report from acertified pathology laboratoryis required for payment.Requires an arch code.A benefit:a. for the removal of thespecimen only.b. once per arch, per date ofservice regardless of theareas involved.Not a benefit with anapicoectomy/periradicularsurgery (D3410-D3426), anextraction (D7111-D7250) andan excision of any soft tissuesor intraosseous lesions(D7410-D7461) in the samearea or region on the samedate of service.

1.

2.

3.

4.

Written documentation for

payment shall include thearea or region and individualareas biopsied.A pathology report from acertified pathology laboratoryis required for payment.A benefit:a. for the removal of thespecimen only.b. up to a maximum ofthree per date of service.Not a benefit with anapicoectomy/periradicular

Written documentation for

payment shall indicate thatthe patient is under activeorthodontic treatment.Requires an arch code.A benefit:a. once per arch.b. only for patients in activeorthodontic treatment.Not a benefit for patients age21 or older.

PROCEDURE D7295HARVEST OF BONE FOR USE INAUTOGENOUS GRAFTINGPROCEDUREThis procedure is not abenefit.

Manual of CriteriaPage 5-85

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

PROCEDURE D7310

4.

ALVEOLOPLASTY INCONJUNCTION WITHEXTRACTIONS FOUR OR MORETEETH OR TOOTH SPACES, PERQUADRANT

5.

1.

2.3.

4.

Radiographs for payment

submit radiographs of theinvolved areas.Requires a quadrant code.A benefit on the same date ofservice with two or moreextractions (D7140-D7250) inthe same quadrant.Not a benefit when only onetooth is extracted in the samequadrant on the same date ofservice.

PROCEDURE D7321ALVEOLOPLASTY NOT INCONJUNCTION WITHEXTRACTIONS ONE TO THREETEETH OR TOOTH SPACES, PERQUADRANTThis procedure can only bebilled as alveoloplasty not inconjunction with extractionsfour or more teeth or toothspaces, per quadrant (D7320).

PROCEDURE D7311ALVEOLOPLASTY INCONJUNCTION WITHEXTRACTIONS ONE TO THREETEETH OR TOOTH SPACES, PERQUADRANTThis procedure can only bebilled as alveoloplasty inconjunction with extractionsfour or more teeth or toothspaces, per quadrant (D7310).

Prior authorization isrequired.Radiographs for priorauthorization submitradiographs.Photographs for priorauthorization submitphotographs.Written documentation forprior authorization- shalldescribe the specificconditions to be addressed bythe procedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the proposedprosthodontic treatment.Requires an arch code.A benefit once in a five yearperiod per arch.Not a benefit:a. on the same date ofservice with a

PROCEDURE D7320ALVEOLOPLASTY NOT INCONJUNCTION WITHEXTRACTIONS FOUR OR MORETEETH OR TOOTH SPACES, PERQUADRANT

A benefit regardless of the

number of teeth or toothspaces.Not a benefit within sixmonths following extractions(D7140-D7250) in the samequadrant, for the sameprovider.

3.

4.

5.6.7.

Prior authorization isrequired.Radiographs for priorauthorization submitradiographs.Photographs for priorauthorization submitphotographs.Written documentation forprior authorization- shalldescribe the specificconditions to be addressed bythe procedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the proposedprosthodontic treatment.Requires an arch code.A benefit once per arch.Not a benefit:a. on the same date ofservice with avestibuloplasty ridgeextension (D7340) samearch.b. on the same date ofservice with extractions(D7111-D7250) samearch.

Radiographs for payment

Effective June 1, 2014

Written documentation for

payment- shall include thetooth involved, describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity and anypertinent history.Requires a quadrant code.A benefit once per quadrant,same date of service.Not a benefit when any otherdefinitive treatment isperformed in the samequadrant on the same date ofservice, except necessaryradiographs and/orphotographs.The fee for this procedureincludes the incision,placement and removal of asurgical draining device.

A benefit once per quadrant,

same date of service.Not a benefit when any otherdefinitive treatment isperformed in the samequadrant on the same date ofservice, except necessaryradiographs and/orphotographs.The fee for this procedureincludes the incision,placement and removal of asurgical draining device.

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

Radiographs for payment

submit a pre-operativeradiograph.Written documentation forpayment- shall include thearea or region, describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity and anypertinent history.A benefit once per date ofservice.Not a benefit when associatedwith the removal of a tumor,cyst (D7440-D7461) or tooth(D7111-D7250).

Radiographs for payment

submit a pre-operativeradiograph.Written documentation forpayment- shall include thearea or region, describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity and anypertinent history.A benefit once per date ofservice.Not a benefit when associatedwith the removal of a tumor,cyst (D7440-D7461) or tooth(D7111-D7250).

Manual of CriteriaPage 5-90

PROCEDURE D7550

PROCEDURE D7610

PARTIAL OSTECTOMY/SEQUESTRECTOMY FORREMOVAL OF NON-VITAL BONE

MAXILLA OPEN REDUCTION

(TEETH IMMOBILIZED, IFPRESENT)

1.

1.

2.

3.4.

5.

Radiographs for payment

submit a pre-operativeradiograph.Written documentation forpayment- shall include thearea or region, describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity and anypertinent history.Requires a quadrant code.A benefit:a. once per quadrant perdate of service.b. only for the removal ofloose or sloughed offdead bone caused byinfection or reducedblood supply.Not a benefit within 30 daysof an associated extraction(D7111-D7250).

Radiographs for payment

submit a pre-operativeradiograph.Written documentation forpayment- shall include thearea or region, describe thespecific conditions addressedby the procedure, therationale demonstrating themedical necessity and anypertinent history.Not a benefit when a toothfragment or foreign body isretrieved from the toothsocket.

2.

3.

4.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit when necessary forthe surgical removal of wires,bands, splints or arch bars.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separateEffective June 1, 2014

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

2.

3.

Effective June 1, 2014

4.

MALAR AND/OR ZYGOMATIC

ARCH OPEN REDUCTION1.

2.

3.

4.

MANDIBLE CLOSED REDUCTION

(TEETH IMMOBILIZED, IFPRESENT)Radiographs for payment submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.The fee for this procedureincludes the placement and

3.

PROCEDURE D7650

PROCEDURE D7640

1.

removal of wires, bands,

splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

MALAR AND/OR ZYGOMATIC

ARCH CLOSED REDUCTION1.

2.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left or

right) and any pertinent

history.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.Requires an arch code.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theManual of CriteriaPage 5-91

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

3.4.

5.

operative report which

describes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.Requires an arch code.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

PROCEDURE D7710

PROCEDURE D7730

MAXILLA OPEN REDUCTION

MANDIBLE OPEN REDUCTION

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.A benefit for the treatment ofsimple fractures.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

Manual of CriteriaPage 5-92

4.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

2.

3.

4.

PROCEDURE D7720MAXILLA CLOSED REDUCTION1.

2.

3.

4.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

PROCEDURE D7740MANDIBLE CLOSED REDUCTION1.

2.

3.

4.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forEffective June 1, 2014

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

the surgical removal of wires,bands, splints or arch bars.

PROCEDURE D7750

4.

MALAR AND/OR ZYGOMATIC

ARCH OPEN REDUCTION1.

2.

3.

4.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

ALVEOLUS OPEN REDUCTION

STABILIZATION OF TEETH1.2.

3.

4.

MALAR AND/OR ZYGOMATIC

ARCH CLOSED REDUCTION

2.

3.

Radiographs for payment

submit a postoperativeradiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.The fee for this procedureincludes the placement and

Effective June 1, 2014

3.

4.

PROCEDURE D7770

PROCEDURE D7760

1.

removal of wires, bands,

splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

Radiographs for payment

submit a radiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

PROCEDURE D7771ALVEOLUS CLOSED REDUCTIONSTABILIZATION OF TEETH1.2.

Radiographs for payment

submit a radiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.

The fee for this procedure

includes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

Radiographs for payment

submit a radiograph.Operative report for payment shall include a copy of theoperative report, whichdescribes the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, the location (left orright) and any pertinenthistory.A benefit for the treatment ofcompound fractures.The fee for this procedureincludes the placement andremoval of wires, bands,splints and arch bars.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary, forthe surgical removal of wires,bands, splints or arch bars.

Written documentation oroperative report for payment shall describe the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.Anesthesia procedures(D9220-D9248) are a separatebenefit, when necessary.

PROCEDURE D7856MYOTOMYWritten documentation oroperative report for payment shall describe the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.

Not a benefit for the closure

Written documentation oroperative report for payment shall include the specificconditions addressed by theprocedure and the length ofthe wound.Not a benefit for the closureof surgical incisions.

PROCEDURE D7912

UNSPECIFIED TMD THERAPY, BY

REPORT

COMPLICATED SUTURE GREATER THAN 5 CM

1.

1.

PROCEDURE D7877ARTHROSCOPY SURGICAL:DEBRIDEMENT

tomograms or a radiologicalreport.Written documentation forprior authorization shallinclude the specific TMJconditions to be addressed bythe procedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.A benefit for diagnosed TMJdysfunction.Not a benefit for thetreatment of bruxism.

2.

3.

4.

Prior authorization is required

for non-emergencyprocedures.Radiographs for priorauthorization submitradiographs and/ortomograms, if applicable, forthe type of procedure.Written documentation forprior authorization shallinclude the specific conditionsto be addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.Not a benefit for proceduressuch as acupuncture,acupressure, biofeedback andhypnosis.

2.

Written documentation oroperative report for payment shall include the specificconditions addressed by theprocedure and the length ofthe wound.Not a benefit for the closureof surgical incisions.

Written documentation oroperative report for payment shall include the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the actualtreatment.Not a benefit for periodontalgrafting.

SUTURE OF RECENT SMALL

WOUNDS UP TO 5 CM

2.

1.

PROCEDURE D7921

Written documentation oroperative report for payment shall include the specificconditions addressed by theprocedure and the length ofthe wound.

COLLECTION AND APPLICATION

OF AUTOLOGOUS BLOODCONCENTRATE PRODUCTThis procedure is not abenefitEffective June 1, 2014

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

PROCEDURE D7940

3.

OSTEOPLASTY FORORTHOGNATHIC DEFORMITIES1.2.

3.

4.

Prior authorization isrequired.Radiographs for priorauthorization submit aradiograph.Written documentation forprior authorization shallinclude the specific conditionsto be addressed by theprocedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the proposedtreatment.An operative report shall besubmitted for payment.

Written documentation for

prior authorization shallinclude the specific conditionsto be addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.An operative report shall besubmitted for payment.

Prior authorization isrequired.Radiographs for priorauthorization submit aradiograph.Written documentation forprior authorization shallinclude the specific conditionsto be addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

SINUS AUGMENTATION WITH

BONE OR BONE SUBSTITUTE VIAA VERTICAL APPROACH

3.

2.

4.

5.

6.7.

Prior authorization isrequired.Radiographs for priorauthorization submit aradiograph.Written documentation forprior authorization shallinclude the specific conditionsto be addressed by theprocedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the proposedtreatment.Not a benefit for periodontalgrafting.An operative report shall besubmitted for payment.

Prior authorization isrequired.Radiographs for priorauthorization submit aradiograph.Written documentation forprior authorization shallinclude the specific conditionsto be addressed by theprocedure, the rationaledemonstrating the medicalnecessity, any pertinenthistory and the proposedtreatment.Not a benefit for periodontalgrafting.

Photographs for payment

submit a pre-operativephotograph.Written documentation forpayment shall include therationale demonstrating themedical necessity and thespecific area the treatmentwas performed.Requires an arch code.A benefita. once per arch per date ofserviceb. only when thepermanent incisors andcuspids have erupted.

PROCEDURE D7963FRENULOPLASTY1.

PROCEDURE D7955REPAIR OF MAXILLOFACIAL SOFTAND/OR HARD TISSUE DEFECT

An operative report shall be

submitted for payment.

2.

3.4.

Photographs for payment

submit a pre-operativephotograph.Written documentation forpayment shall include therationale demonstrating themedical necessity and thespecific area the treatmentwas performed.Requires an arch code.A benefita. once per arch per date ofservice.b. only when thepermanent incisors andcuspids have erupted.

Effective June 1, 2014

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

PROCEDURE D7970

PROCEDURE D7972

EXCISION OF HYPERPLASTICTISSUE PER ARCH

SURGICAL REDUCTION OFFIBROUS TUBEROSITY

1.

1.

2.

3.4.5.

6.

Photographs for payment

submit a pre-operativephotograph.Written documentation forpayment shall include therationale demonstrating themedical necessity and thespecific area the treatmentwas performed.Requires an arch code.A benefit once per arch perdate of service.Not a benefit for drug inducedhyperplasia or where removalof tissue requires extensivegingival recontouring.This procedure is included inthe fees for other surgicalprocedures that areperformed in the same areaon the same date of service.

PROCEDURE D7971EXCISION OF PERICORONALGINGIVA1.

2.

3.

4.5.

Radiographs for paymentsubmit a pre-operative

periapical radiograph.Photographs for payment submit a pre-operativephotograph only when theradiograph does notadequately demonstrate themedical necessity.Written documentation forpayment shall include therationale demonstrating themedical necessity.Requires a tooth code.This procedure is included inthe fee for other associatedprocedures that areperformed on the same toothon the same date of service.

Effective June 1, 2014

2.

3.4.5.

Photographs for payment

submit a pre-operativephotograph.Written documentation forpayment shall include therationale demonstrating themedical necessity and theactual or proposedprosthodontic treatment.Requires a quadrant code.A benefit once per quadrantper date of service.This procedure is included inthe fees for other surgicalprocedures that areperformed in the samequadrant on the same date ofservice.

necessity and any pertinent

history.

PROCEDURE D7982SIALODOCHOPLASTYOperative report for payment shall include the area orregion the treatment wasperformed, the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.

PROCEDURE D7983CLOSURE OF SALIVARY FISTULAOperative report for payment shall include the area orregion the treatment wasperformed, the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.

PROCEDURE D7980SIALOLITHOTOMY1.

2.

Radiographs for payment

submit a pre-operativeradiograph.Written documentation oroperative report for payment shall include the area orregion the treatment wasperformed, the specificconditions addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.

PROCEDURE D7981EXCISION OF SALIVARY GLAND,BY REPORTOperative report for payment shall include the area orregion the treatment wasperformed, the specificconditions addressed by theprocedure, the rationaledemonstrating the medical

PROCEDURE D7990EMERGENCY TRACHEOTOMYOperative report for payment shall include the specificconditions addressed by theprocedure.

PROCEDURE D7991CORONOIDECTOMY1.2.

3.

Prior authorization isrequired.Radiographs for priorauthorization submit aradiograph.Written documentation forprior authorization shallinclude the specific conditionsto be addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.Manual of CriteriaPage 5-99

Oral and Maxillofacial Surgery Procedures (D7000-D7999)

4.

An operative report shall be

submitted for payment.

4.

PROCEDURE D7995SYNTHETIC GRAFT MANDIBLEOR FACIAL BONES, BY REPORT1.2.

3.

4.5.

Prior authorization isrequired.Radiographs for priorauthorization submit aradiograph.Written documentation forprior authorization shallinclude the specific conditionsto be addressed by theprocedure, the rationaledemonstrating the medicalnecessity and any pertinenthistory.Not a benefit for periodontalgrafting.An operative report shall besubmitted for payment.

This procedure is not a

A benefit:a. once per arch per date ofservice.b. for the removal ofappliances related tosurgical procedures only.Not a benefit for the removalof orthodontic appliances andspace maintainers.

4.

Radiographs for payment

submit radiographs ifapplicable for the type ofprocedure.Photographs for payment submit photographs ifapplicable for the type ofprocedure.Written documentation oroperative report describethe specific conditionsaddressed by the procedure,the rationale demonstratingthe medical necessity, anypertinent history and theactual treatment.Procedure D7999 shall beused:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patienthas an exceptionalmedical condition tojustify the medicalnecessity.Effective June 1, 2014

Orthodontic General Policies (D8000-D8999)

Orthodontic General Policies (D8000-D8999)

1.

Orthodontic Procedures (D8080, D8660, D8670 and D8680)

A) Orthodontic procedures shall only be performed by dentists who qualify as orthodontists under theCalifornia Code of Regulations, Title 22, Section 51223(c).B) Orthodontic procedures are benefits for medically necessary handicapping malocclusion, cleft palate andfacial growth management cases for patients under the age of 21 and shall be prior authorized.C) Only those cases with permanent dentition shall be considered for medically necessary handicappingmalocclusion, unless the patient is age 13 or older with primary teeth remaining. Cleft palate andcraniofacial anomaly cases are a benefit for primary, mixed and permanent dentitions. Craniofacialanomalies are treated using facial growth management.D) All necessary procedures that may affect orthodontic treatment shall be completed before orthodontictreatment is considered.E) Orthodontic procedures are a benefit only when the diagnostic casts verify a minimum score of 26 pointson the Handicapping Labio-Lingual Deviation (HLD) Index California Modification Score Sheet Form, DC016(06/09) or one of the six automatic qualifying conditions below exist or when there is writtendocumentation of a craniofacial anomaly from a credentialed specialist on their professional letterhead.F) The automatic qualifying conditions are:i) cleft palate deformity. If the cleft palate is not visible on the diagnostic casts written documentationfrom a credentialed specialist shall be submitted, on their professional letterhead, with the priorauthorization request,ii) craniofacial anomaly. Written documentation from a credentialed specialist shall be submitted, ontheir professional letterhead, with the prior authorization request,iii) a deep impinging overbite in which the lower incisors are destroying the soft tissue of the palate,iv) a crossbite of individual anterior teeth causing destruction of soft tissue,v) an overjet greater than 9 mm or reverse overjet greater than 3.5 mm,vi) a severe traumatic deviation (such as loss of a premaxilla segment by burns, accident or osteomyelitisor other gross pathology). Written documentation of the trauma or pathology shall be submitted withthe prior authorization request.G) When a patient transfers from one orthodontist to another orthodontist, a new TAR for priorauthorization shall be submitted:i) when the patient has already qualified under the Medi-Cal Dental Program and has been receivingtreatment, the balance of the originally authorized treatment shall be authorized to the neworthodontist to complete the case. Diagnostic casts, Handicapping Labio-Lingual Deviation (HLD)Index California Modification Score Sheet Form, DC016 (06/09), and photographs are not required fora transfer case that has already been approved, orii) when a patient has been receiving orthodontic treatment that has not been previously approved bythe Medi-Cal Dental Program, pre-treatment diagnostic casts and current photographs are required.If pre-treatment diagnostic casts are not available then current diagnostic casts shall be submitted.Prior authorization for the balance of the orthodontic treatment shall be allowed or denied based onthe Medi-Cal Dental Programs evaluation of the diagnostic casts and photographs.H) When additional periodic orthodontic treatment visit(s) (D8670) are necessary beyond the maximumallowed to complete the case, prior authorization is required. Current photographs are required to justifythe medical necessity.I) If the patients orthodontic treatment extends beyond the month of their 21st birthday or they becomeineligible during treatment, then it is the patients responsibility to pay for their continued treatment.J) If the patients orthodontic treatment is interrupted and orthodontic bands are prematurely removed,then the patient no longer qualifies for continued orthodontic treatment.

Effective June 1, 2014

Manual of CriteriaPage 5-101

Orthodontic General Policies (D8000-D8999)

K) If the patients orthodontic bands have to be temporarily removed and then replaced due to a medicalnecessity, a claim for comprehensive orthodontic treatment of the adolescent dentition (D8080) forrebanding shall be submitted along with a letter from the treating physician or radiologist, on theirprofessional letterhead, stating the reason why the bands needed to be temporarily removed.

Manual of CriteriaPage 5-102

Effective June 1, 2014

Orthodontic Procedures (D8000-D8999

Orthodontic Procedures (D8000-D8999)

PROCEDURE D8010

PROCEDURE D8070

LIMITED ORTHODONTICTREATMENT OF THE PRIMARYDENTITION

COMPREHENSIVE ORTHODONTICTREATMENT OF THETRANSITIONAL DENTITION

This procedure is not a

benefit.

This procedure is not a

benefit.

PROCEDURE D8020

PROCEDURE D8080

LIMITED ORTHODONTICTREATMENT OF THETRANSITIONAL DENTITION

COMPREHENSIVE ORTHODONTICTREATMENT OF THE ADOLESCENTDENTITION

This procedure is not a

benefit.

1.

PROCEDURE D8030LIMITED ORTHODONTICTREATMENT OF THE ADOLESCENTDENTITIONThis procedure is not abenefit.

PROCEDURE D8040LIMITED ORTHODONTICTREATMENT OF THE ADULTDENTITIONThis procedure is not abenefit.

PROCEDURE D8050INTERCEPTIVE ORTHODONTICTREATMENT OF THE PRIMARYDENTITIONThis procedure is not abenefit.

2.

PROCEDURE D8060INTERCEPTIVE ORTHODONTICTREATMENT OF THETRANSITIONAL DENTITIONThis procedure is not abenefit.

on their professionalletterhead, if the cleftpalate is not visible onthe diagnostic casts, orb. facial growthmanagement casesrequire documentationfrom a credentialedspecialist, on theirprofessional letterhead,of the craniofacialanomaly.A benefit:a. for handicappingmalocclusion, cleft palateand facial growthmanagement cases.b. for patients under theage of 21.c. for permanent dentition(unless the patient is age13 or older with primaryteeth still present or hasa cleft palate orcraniofacial anomaly).d. once per patient perphase of treatment.All appliances (such as bands,arch wires, headgear andpalatal expanders) areincluded in the fee for thisprocedure. No additionalcharge to the patient ispermitted.This procedure includes thereplacement, repair andremoval of brackets, bandsand arch wires by the originalprovider.

PROCEDURE D8090COMPREHENSIVE ORTHODONTICTREATMENT OF THE ADULTDENTITIONThis procedure is not abenefit.Manual of CriteriaPage 5-103

for patients ages 6

through 12.b. once per patient.Not a benefit:a. for orthodonticappliances, toothguidance appliances,minor tooth movement,or activating wires.b. for space maintainers inthe upper or loweranterior region.This procedure includes alladjustments to the appliance.

Index CaliforniaModification Score SheetForm, DC016 (06/09).Written documentation forprior authorization- shallinclude a letter from acredentialed specialist, ontheir professional letterhead,confirming a craniofacialanomaly.A benefit:a. prior to comprehensiveorthodontic treatment ofthe adolescent dentition(D8080) for the initialtreatment phase forfacial growthmanagement casesregardless of how manydentition phases arerequired.b. once every three months.c. for patients under theage of 21.d. for a maximum of six.

Prior authorization isrequired. Refer toOrthodontic General Policiesfor specific authorizationrequirements.The start of payments for thisprocedure shall be the nextcalendar month following thedate of service forcomprehensive orthodontictreatment of the adolescentdentition (D8080).A benefit:a. for patients under theage of 21.b. for permanent dentition(unless the patient is age13 or older with primaryEffective June 1, 2014

which is considered to be the

active phase of orthodontictreatment.Requires an arch code.A benefit:a. for patients under theage of 21.b. for permanent dentition(unless the patient is age13 or older with primaryteeth still present or hasa cleft palate orcraniofacial anomaly).c. once per arch for eachauthorized phase oforthodontic treatment.Not a benefit until the activephase of orthodontictreatment (D8670) iscompleted. If fewer than theauthorized number ofperiodic orthodontictreatment visit(s) (D8670) arenecessary because the activephase of treatment has beencompleted early, then thisshall be documented on theclaim for orthodonticretention (D8680).The removal of appliances,construction and placementof retainers, all observationsand necessary adjustmentsare included in the fee for thisprocedure.

Orthodontic Procedures (D8000-D8999

This procedure does not

require prior authorization.Written documentation forpayment indicate the typeof orthodontic appliance anda description of the repair.Requires an arch code.A benefit:a. for patients under theage of 21.b. once per appliance.Not a benefit to the originalprovider for the replacementand/or repair of brackets,bands, or arch wires.

1.2.

3.4.

5.

PROCEDURE D8692REPLACEMENT OF LOST ORBROKEN RETAINER1.2.

3.4.

5.

This procedure does not

require prior authorization.Written documentation forpayment indicate how theretainer was lost or why it isno longer serviceable.Requires an arch code.A benefit:a. for patients under theage of 21.b. once per arch.c. only within 24 monthsfollowing the date ofservice of orthodonticretention (D8680).This procedure is only payablewhen orthodontic retention(D8680) has been previouslypaid by the program.

PROCEDURE D8999UNSPECIFIED ORTHODONTICPROCEDURE, BY REPORT1.

2.

3.

4.

Manual of CriteriaPage 5-106

This procedure does not

require prior authorization.Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires an arch code.A benefit:a. for patients under theage of 21.b. once per provider.Additional requests beyondthe stated frequencylimitations shall be consideredfor payment when themedical necessity isdocumented and identifies anunusual condition (such asdisplacement due to a stickyfood item).

5.6.

7.

rationale demonstrating the

medical necessity, anypertinent history and theproposed or actual treatment.A benefit for patients underthe age of 21.Not a benefit to the originalprovider for the adjustment,repair, replacement orremoval of brackets, bands orarch wires.Procedure D8999 shall beused:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patienthas an exceptionalmedical condition tojustify the medicalnecessity.Documentation shallinclude the medicalcondition and the specificCDT code associated withthe treatment.

Prior authorization is required

for non-emergencyprocedures.Radiographs for priorauthorization or paymentsubmit radiographs ifapplicable for the type ofprocedure.Photographs for priorauthorization or paymentsubmit photographs ifapplicable for the type ofprocedure.Written documentation forprior authorization orpayment describe thespecific conditions addressedby the procedure, theEffective June 1, 2014

Adjunctive General Policies (D9000-D9999)

Adjunctive General Policies (D9000-D9999)

1.2.

Anesthesia (D9210-D9248)General anesthesia (D9220 and D9221) is defined as a controlled state of unconsciousness, accompanied by apartial or complete loss of protective reflexes, including the loss of the ability to independently maintain anairway and respond purposefully to physical stimulation or verbal command, produced by a pharmacologic ornon-pharmacologic method or combination thereof.3. Intravenous sedation/analgesia (D9241 and D9242) is a medically controlled state of depressed consciousnesswhile maintaining the patients airway, protective reflexes and the ability to respond to stimulation or verbalcommands. It includes intravenous (IV) administration of sedative and/or analgesic agent(s) and appropriatemonitoring.4. Non-intravenous conscious sedation (D9248) is a medically controlled state of depressed consciousness whilemaintaining the patients airway, protective reflexes and the ability to respond to stimulation or verbalcommands. It includes administration of sedative and/or analgesic agent(s) by a route other than IV (oral,patch, intramuscular or subcutaneous) and appropriate monitoring.5. Deep sedation/general anesthesia (D9220 and D9221) and intravenous conscious sedation/analgesia (D9241and D9242) shall be considered for payment when it is documented why local anesthesia is contraindicated.Such contraindications shall include the following:A) a severe mental or physical handicap,B) extensive surgical procedures,C) an uncooperative child,D) an acute infection at an injection site,E) a failure of a local anesthetic to control pain.6. The administration of deep sedation/general anesthesia (D9220 and D9221), nitrous oxide (D9230),intravenous conscious sedation/analgesia (D9241 and D9242) and therapeutic parenteral drug (D9610) is abenefit in conjunction with payable associated procedures. Prior authorization or payment shall be denied ifall associated procedures by the same provider are denied.7. Only one anesthesia procedure is payable per date of service regardless of the methods of administration ordrugs used. When one or more anesthesia procedures are performed only the most profound procedure willbe allowed. The following anesthesia procedures are listed in order from most profound to least profound:A) Procedure D9220/D9221 (Deep Sedation/General Anesthesia),B) Procedure D9241/D9242 (Intravenous Conscious Sedation/Analgesia),C) Procedure D9248 (Non-Intravenous Conscious Sedation),D) Procedure D9230 (Inhalation Of Nitrous Oxide/Analgesia, Anxiolysis).8. Providers who administer general anesthesia (D9220 and D9221) and/or intravenous conscioussedation/analgesia (D9241 and D9242) shall have valid anesthesia permits with the California Dental Board.9. The cost of analgesic and anesthetic agents and supplies are included in the fee for the analgesic/ anestheticprocedure.10. Anesthesia time for general anesthesia and intravenous conscious sedation is defined as the period betweenthe beginning of the administration of the anesthetic agent and the time that the anesthetist is no longer inpersonal attendance.11. Sedation is a benefit in conjunction with the surgical removal of wires, bands, splints and arch bars.

Effective June 1, 2014

Manual of CriteriaPage 5-107

Adjunctive General Policies (D9000-D9999)

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Manual of CriteriaPage 5-108

Effective June 1, 2014

Adjunctive Service Procedures (D9000-D9999)

Adjunctive Service Procedures (D9000-D9999)

This procedure cannot be

prior authorized.Written documentation forpayment shall include thetooth/area, condition andspecific treatment performed.A benefit once per date ofservice per providerregardless of the number ofteeth and/or areas treated.Not a benefit when any othertreatment is performed onthe same date of service,except whenradiographs/photographs areneeded of the affected areato diagnose and documentthe emergency condition.

PROCEDURE D9120FIXED PARTIAL DENTURESECTIONING1.2.

3.4.

This procedure does not

require prior authorization.Radiographs for paymentsubmit pre-operativeradiographs.Requires a tooth code for theretained tooth.A benefit when at least one ofthe abutment teeth is to beretained.

This procedure cannot be

prior authorized.Written documentation forpayment shall include the

Effective June 1, 2014

3.

4.

medical necessity for the local

anesthetic injection.A benefit:a. once per date of serviceper provider.b. only for use in order toperform a differentialdiagnosis or as atherapeutic injection toeliminate or control adisease or abnormalstate.Not a benefit when any othertreatment is performed onthe same date of service,except whenradiographs/photographs areneeded of the affected areato diagnose and documentthe emergency condition.

PROCEDURE D9211REGIONAL BLOCK ANESTHESIAThis procedure is included inthe fee for other proceduresand is not payable separately.

PROCEDURE D9212TRIGEMINAL DIVISION BLOCKANESTHESIAThis procedure is included inthe fee for other proceduresand is not payable separately.

PROCEDURE D9215LOCAL ANESTHESIA INCONJUNCTION WITH OPERATIVEOR SURGICAL PROCEDURESThis procedure is included inthe fee for other proceduresand is not payable separately.

This procedure does not

require prior authorization.Written documentation forpayment shall justify themedical necessity based on amental or physical limitationor contraindication to a localanesthetic agent. Theanesthetic induction agentshall also be documented.An anesthesia record thatindicates the anestheticagent(s) and the anesthesiatime shall be submitted forpayment.Not a benefit:a. on the same date ofservice as analgesia,anxiolysis, inhalation ofnitrous oxide (D9230),intravenous conscioussedation/analgesia(D9241 and D9242) ornon-intravenousconscious sedation(D9248).b. when all associatedprocedures on the samedate of service by thesame provider aredenied.

This procedure does not

Adjunctive Service Procedures (D9000-D9999)

3.

4.

5.

mental or physical limitation

or contraindication to a localanesthetic agent. Theanesthetic induction agentshall also be documented.An anesthesia record thatindicates the anestheticagent(s) and the anesthesiatime shall be submitted forpayment.The quantity, in 15-minuteincrements, that wasnecessary to complete thetreatment shall be indicatedon the claim.Not a benefit:a. on the same date ofservice as analgesia,anxiolysis, inhalation ofnitrous oxide (D9230),intravenous conscioussedation/analgesia(D9241 and D9242) ornon-intravenousconscious sedation(D9248).b. when all associatedprocedures on the samedate of service by thesame provider aredenied.

a.

4.

for uncooperativepatients under the age of13, orb. for patients age 13 orolder whendocumentationspecifically identifies thephysical, behavioral,developmental oremotional condition thatprohibits the patientfrom responding to theproviders attempts toperform treatment.Not a benefit:a. on the same date ofservice as deepsedation/generalanesthesia (D9220 andD9221), intravenousconscioussedation/analgesia(D9241 and D9242) ornon-intravenousconscious sedation(D9248).b. when all associatedprocedures on the samedate of service by thesame provider aredenied.

This procedure does not

require prior authorization.Written documentation forpayment shall justify themedical necessity based on amental or physical limitationor contraindication to a localanesthetic agent.An anesthesia record thatindicates the anestheticagent(s) and the anesthesia

4.

time shall be submitted for

payment.Not a benefit:a. on the same date ofservice as deepsedation/generalanesthesia (D9220 andD9221), analgesia,anxiolysis, inhalation ofnitrous oxide (D9230) ornon-intravenousconscious sedation(D9248).b. when all associatedprocedures on the samedate of service by thesame provider aredenied.

This procedure does not

require prior authorization.Written documentation forpayment shall justify themedical necessity based on amental or physical limitationor contraindication to a localanesthetic agent.An anesthesia record thatindicates the anestheticagent(s) and the anesthesiatime shall be submitted forpayment.The quantity, in 15-minuteincrements, that wasnecessary to complete thetreatment shall be indicatedon the claim.Not a benefit:a. on the same date ofservice as deepsedation/generalanesthesia (D9220 andD9221), analgesia,anxiolysis, inhalation ofEffective June 1, 2014

Adjunctive Service Procedures (D9000-D9999)

b.

nitrous oxide (D9230) or

non-intravenousconscious sedation(D9248).when all associatedprocedures on the samedate of service by thesame provider aredenied.

Effective June 1, 2014

subcutaneous routes ofadministration.d. once per date of service.Not a benefit:a. on the same date ofservice as deepsedation/generalanesthesia (D9220 andD9221), analgesia,anxiolysis, inhalation ofnitrous oxide (D9230) orintravenous conscioussedation/analgesia(D9241 and D9242).b. when all associatedprocedures on the samedate of service by thesame provider aredenied.

the reason why the

patient cannot leave theirprivate residence, andc. the length of time thepatient will behomebound.A benefit:a. once per patient per dateof service.b. only in conjunction withprocedures that arepayable.When this procedure issubmitted for paymentwithout associatedprocedures, the medicalnecessity for the visit shall bedocumented and justified.

3.

The operative report for

payment shall include thetotal time in the operatingroom or ambulatory surgicalcenter.A benefit for each hour orfraction thereof asdocumented on the operativereport.Not a benefit:a. for an assistant surgeon.b. for time spent compilingthe patient history,writing reports or forpost-operative or followup visits.

PROCEDURE D9430OFFICE VISIT FOR OBSERVATION(DURING REGULARLY SCHEDULEDHOURS) NO OTHER SERVICESPERFORMED1.2.

This procedure cannot be

Adjunctive Service Procedures (D9000-D9999)

3.4.

tooth/area, the chief

complaint and the non-clinicaltreatment taken.A benefit once per date ofservice per provider.Not a benefit:a. when procedures otherthan necessaryradiographs and/orphotographs areprovided on the samedate of service.b. for visits to patientsresiding in ahouse/extended carefacility.

PROCEDURE D9440OFFICE VISIT AFTER REGULARLYSCHEDULED HOURS1.2.

3.

4.

This procedure cannot be

prior authorized.Written documentation forpayment shall includejustification of the emergency(chief complaint) and bespecific to an area or tooth.The time and day of the weekshall also be documented.A benefita. once per date of serviceper provider.b. only with treatment thatis a benefit.This procedure is tocompensate providers fortravel time back to the officefor emergencies outside ofregular office hours.

Written documentation for

payment shall include thespecific drug name andclassification.A benefit for up to amaximum of four injectionsper date of service.Not a benefit:a. for the administration ofan analgesic or sedativewhen used in conjunctionwith deepsedation/generalanesthesia (D9220 andD9221), analgesia,anxiolysis, inhalation ofnitrous oxide (D9230),intravenous conscioussedation/analgesia(D9241 and D9242) ornon-intravenousconscious sedation(D9248).b. when all associatedprocedures on the samedate of service by thesame provider aredenied.

2.

3.

4.

PROCEDURE D9911APPLICATION OF DESENSITIZINGRESIN FOR CERVICAL AND/ORROOT SURFACE, PER TOOTHThis procedure is not abenefit.

PROCEDURE D9920BEHAVIOR MANAGEMENT, BYREPORT

PROCEDURE D9612THERAPEUTIC PARENTERALDRUG, TWO OR MOREADMINISTRATIONS, DIFFERENTMEDICATIONSThis procedure can only bebilled as therapeuticparenteral drug, singleadministration (D9610).

PROCEDURE D9630

This procedure is not a

OTHER DRUGS AND/OR

MEDICAMENTS, BY REPORTThis procedure is not abenefit.

This procedure cannot be

prior authorized.Written documentation forpayment shall include thetooth/teeth and the specifictreatment performed.A benefit:a. once in a 12-monthperiod per provider.b. for permanent teethonly.Not a benefit:a. when used as a base,liner or adhesive under arestoration.b. the same date of serviceas fluoride (D1206 andD1208).

This procedure cannot be

Adjunctive Service Procedures (D9000-D9999)

a.

5.

once per date of service

per provider.b. for the treatment of a drysocket or excessivebleeding within 30 daysof the date of service ofan extraction.c. for the removal of bonyfragments within 30 daysof the date of service ofan extraction.Not a benefit:a. for the removal of bonyfragments on the samedate of service as anextraction.b. for routine postoperative visits.

b.

4.5.

PROCEDURE D9951OCCLUSAL ADJUSTMENT LIMITED1.

PROCEDURE D9940OCCLUSAL GUARD, BY REPORTThis procedure is not abenefit.

PROCEDURE D9941

2.3.

FABRICATION OF ATHLETICMOUTHGUARDThis procedure is not abenefit.

PROCEDURE D9942REPAIR AND/OR RELINE OFOCCLUSAL GUARD

4.

This procedure is not a

benefit.

PROCEDURE D9950OCCLUSION ANALYSIS MOUNTED CASE1.

Prior authorization isrequired.2. Written documentation forprior authorization shalldescribe the specificsymptoms with a detailedhistory and diagnosis.3. A benefit:a. once in a 12-monthperiod.Effective June 1, 2014

for patients age 13 or

older.c. for diagnosed TMJdysfunction only.d. for permanent dentition.Not a benefit for bruxismonly.The fee for this procedureincludes face bow,interocclusal record tracings,diagnostic wax up anddiagnostic casts.

Submission of radiographs,photographs or writtendocumentationdemonstrating medicalnecessity is not required forpayment.Requires a quadrant code.A benefit:a. once in a 12-monthperiod per quadrant perprovider.b. for patients age 13 orolder.c. for natural teeth only.Not a benefit within 30 daysfollowing definitiverestorative, endodontic,removable and fixedprosthodontic treatment inthe same or opposingquadrant.

Adjunctive Service Procedures (D9000-D9999)

PROCEDURE D9975EXTERNAL BLEACHING FOR HOMEAPPLICATION, PER ARCH;INCLUDES MATERIALS ANDFABRICATION OF CUSTOM TRAYSThis procedure is not abenefit.

PROCEDURE D9999UNSPECIFIED ADJUNCTIVEPROCEDURE, BY REPORT1.

2.

3.

4.

5.

Prior authorization is required

for non-emergencyprocedures.Radiographs for priorauthorization or payment submit radiographs ifapplicable for the type ofprocedure.Photographs for priorauthorization or payment submit photographs ifapplicable for the type ofprocedure.Written documentation forprior authorization orpayment shall include a fulldescription of the proposedor actual treatment and themedical necessity.Procedure D9999 shall beused:a. for a procedure which isnot adequately describedby a CDT code, orb. for a procedure that has aCDT code that is not abenefit but the patienthas an exceptionalmedical condition tojustify the medicalnecessity.Documentation shallinclude the medicalcondition and the specificCDT code associated withthe treatment.

Manual of CriteriaPage 5-114

Effective June 1, 2014

Denti-Cal Schedule of Maximum Allowances

1.

2.

Fees payable to providers by Denti-Cal for covered services shall be the LESSER of:a. providers billed amountb. the maximum allowance set forth in the schedule belowRefer to your Medi-Cal Dental Program Provider Handbook for specific procedure instructions and programlimitations.

Benefit: Dental or medical health care services covered by the Medi-Cal programNot a Benefit: Dental or medical health care services not covered by the Medi-Cal programGlobal: Treatment performed in conjunction with another procedure which is not payable separatelyBy Report: Payment amount determined from submitted documentation.CDTCodes

Maximum $$Allowance

Procedure Code Description

DiagnosticD0120

Periodic oral evaluation - established patient

$15.00

D0140

Limited oral evaluation problem focused

$35.00

D0145

Oral evaluation for a patient under three years of age and counseling with primarycaregiver

Only Denti-Cal specific, State-approved forms, are

accepted by Denti-Cal. Any other forms will bereturned without processing. Proper use andcompletion of these forms will expedite authorizationor payment for Denti-Cal covered services. Noduplicates or photocopies will be accepted orprocessed. Signatures in blue or black ink arerequired: rubber signature stamps will not beaccepted.

When ordering forms, be sure to request an

adequate supply of TAR/Claim forms, CIFs, andJustification of Need for Prosthesis forms, plus X-rayand mailing envelopes. The Forms Reorder Request(DC-204) is to be used to order forms from the DentiCals forms supplier.

Treatment Authorization Request (TAR)/ Claim

Forms

DC-202 Preimprinted, No Carbon Required

(NCR)DC-209 NCR for continuous pin-fedprintersDC-217 Single sheet for laser printers

Claim Inquiry Forms (CIFs)

DC-003

Envelopes for TAR/Claim Forms/ Correspondence

DC-006C for submitting

The forms vendor will verify that the National

Provider Identifier (NPI) number submitted forpreimprinting matches what is on record at Denti-Cal.Once confirmed, the inventory will be preimprintedwith the NPI. However, if the information found onthe Forms Reorder Request does not match what theforms vendor has received from Denti-Cal, the orderwill not be filled.The Forms Reorder Request form (DC-204) should bemailed or faxed to the warehouse vendor:Denti-Cal Forms Reorder11155 International Drive, MS C25Rancho Cordova, CA 95670Fax: (877) 401-7534Do not phone the warehouse: they are not staffed tohandle telephone requests.Upon receiving Denti-Cal forms and envelopes, verifythat any pre-printed information such as addressand/or NPI number is correct. If there are errors, thenplease call the Denti-Cal toll free at (800) 423-0507.

Envelopes for Submitting Radiographs

DC-014E large envelopes for submitting

radiographs with EDIDC-014F small envelopes for submittingradiographs with EDIDC-214A large envelopes for submittingradiographs with TAR/Claim formsDC-214B small envelopes for submittingradiographs with TAR/Claim forms

Use only Denti-Cal provided forms

On TAR/Claim forms, leave boxes 11 through18 blank, unless indicating yes. OCR readsany mark in boxes 11 through 18 as a yes,even if the answer is no.Use a laser printer for best results. Ifhandwritten documents must be submitted,use neat block letters, blue or black ink, andstay within field boundaries.Use a 10 point, plain font (such as Arial), anduse all capital lettersUse a 6-digit date format without dashes orslashes, e.g., mmddyy (123116)Use only Denti-Cal TAR/Claim formsPrint within the lines of the appropriate fieldSubmit notes and attachments on 8 " by 11"paper. Small attachments must be taped tostandard paper in order to go through thescanner.Submit notes and attachments on one side ofthe paper only. Double-sided attachmentsrequire copying and additional preparation forthe scanners which will cause delays inadjudication.Enter quantity information in the quantityfield. OCR does not read the description ofservice field to pick up the quantity.On TAR/Claim forms, complete boxes 19 and20. Enter the complete Billing Provider Nameand NPI to ensure appropriate payment to thecorrect billing number.Remember that the following TAR/Claim formsare no longer available and should not be used:DC-002A, DC-002B, DC-009A, DC-009B, DC017A, and DC-017BAlways apply a handwritten signature in blueor black ink

Third Quarter, 2016

Do Not:

Use correction fluid or tape

Use a dot matrix/impact printerUse italics or script fontsMix fonts on the same formUse fonts smaller than 10 pointUse arrows or quote/ditto marks to indicateduplicate dates of service, National ProviderIdentifier (NPI), etc.Use dashes or slashes in date fieldsPrint slashed zerosUse photocopies of any Denti-Cal formsUse highlighters to highlight field information(this causes field data to turn black andbecome unreadable)Submit two-sided attachmentsEnter quantity information in the descriptionof service fieldPut notes on the top or bottom of formsFold any formsUse labels, stickers, or stamps on any Denti-CalformsUse rubber signature or signature on filestampsPlace additional forms, attachments, ordocumentation inside the X-ray envelope. Thiswill cause a delay in adjudication andprocessing.

FormsPage 6-3

Correct Use of Denti-Cal Envelopes

Denti-Cal continues to receive X-ray envelopes thatare incorrectly addressed or prepared, have noaddress, or are empty. Some providers also submitradiographs without using the correct preimprintedor typed X-ray envelopes specifically designed forthat purpose. Radiographs and photographs will notbe returned.

FormsPage 6-4

When submitting claims for multiple patients

in one envelope, ensure that theradiographs/photographs for the respectivepatient are stapled to the associatedclaim/TAR. Use only one staple in upper rightor left corner of the claim/TAR to attachradiographs or paper copies.Do not print two separate documents on onepiece of paper (e.g., an EDI Notice ofAuthorization for one beneficiary on oneside, and another EDI Notice ofAuthorization for a different beneficiary onthe other side).Enclose mounted, dated, and well-markedradiographs and photographs in theappropriate X-ray envelope. Include thedentist's name, Denti-Cal provider number,and beneficiary name and Medi-Cal IDnumber on the X-Ray mount. Duplicateradiographs, paper radiographs, andphotographs should also be marked clearlyso they are identifiable for processing. Thedate on all radiographs, paper copies, andphotographs must be in month/date/yearformat.Plastic sleeve mounts should be clean andhave the label containing the requiredinformation placed on the front side of themount.If the provider has a device such as a scannerthat can transfer radiographs onto paper,Denti-Cal will accept the paper copy insteadof the regular film. Paper copies ofradiographs must be of good quality to beaccepted and must be larger than 2 inchesby 3.5 inches (about the size of a businesscard). If the resolution of the paper image isinadequate, Denti-Cal will request theoriginal film, which can delay processing. Be

sure to indicate on the paper copy the date

the radiograph was taken and which side ofthe mouth. Paper copies of radiographs willnot be returned.Paper copies should be printed on 20lb orheavier paper, but do not use glossy orphoto paper.Do not fold radiographs or photographs.Only use X-ray envelopes for radiographs orpaper radiographs. All other attachmentsand documentation should be stapled to theTAR/Claim form to reduce processing delays.Do not overfill X-ray envelopes. Theappropriately-sized envelopes should beused for all radiographs submitted toprevent damaged envelopes and/or lostradiographs.Up to three unmounted radiographs may besubmitted by placing them in unsealed coinsize envelopes and inserting the coin-sizeenvelopes into the X-ray envelopes providedby Denti-Cal. The coin-sized envelope shouldbe labeled with the provider name, NPI,beneficiary name, and date.

Denti-Cal offers the following special envelopes to be

used by the dental office for enclosingradiographs/photographs with claim and TAR forms:

DC-014E Large envelopes for submitting

radiographs/photographs with EDIdocumentsDC-014F Small envelope for submittingradiographs/photographs with EDIdocumentsDC-214A Large envelopes for submittingradiographs/photographs with theseTAR/Claims: DC-20w2, DC-209, DC-217DC-214B Small envelopes for submittingradiographs/photographs with theseTAR/Claims: DC-202, DC-209, DC-217

Radiographs should be placed in these envelopes.

Loose radiographs can become separated and lost,which can delay the time it takes Denti-Cal to processdocuments.Denti-Cal also provides the following envelopes formailing TAR/Claim forms:Third Quarter, 2016

Third Quarter, 2016

FormsPage 6-5

Treatment Authorization Request

(TAR)/Claim FormsThe TAR/Claim form is used to request authorizationof proposed treatment or submit a claim forpayment. Accurate completion of this form isrequired to ensure proper and expeditious handlingby Denti-Cal. An incomplete or inaccurate TAR orClaim will delay processing and may result in thegeneration of a RTD or denial.Denti-Cal-specific forms are the only forms processedunder the Denti-Cal Program, whether forauthorization of covered services or payment ofrendered treatment.The format of the following forms is identical.

DC-202 (No Carbon Required (NCR)

For scanning purposes, the forms are produced with

red ink, and providers are requested to use only blueor black ink on any forms submitted to Denti-Cal.Please make sure all applicable areas of the forms arefilled in completely and accurately. Any claim serviceline (CSL) submitted with an invalid procedure codeor a blank procedure code field will be denied,whether submitted electronically or as paperdocuments. Documents received with a missing orincorrect address or NPI can delay the processing ofTARs and claims and increase the possibility thatpayments may be forwarded to the wrong office.

FormsPage 6-6

Third Quarter, 2016

Sample TAR/Claim Form Submitted as a Treatment Authorization Request (TAR)

Third Quarter, 2016

FormsPage 6-7

Sample TAR/Claim Form Submitted as a Claim

FormsPage 6-8

Third Quarter, 2016

How to Complete the TAR/Claim Form

Accurate and complete preparation of this form isessential for processing. Unless otherwise specified,all fields must be completed.Denti-Cal's evaluation of TARs and Claims will bemore accurate when narrative documentation isincluded. The following reminders and tips help officestaff prepare narrative documentation for somecommon Denti-Cal procedures:

Comments area (Field 34) of the

TAR/Claim form is used when writtennarrative documentation is required. Ifincluding narrative documentation on aseparate piece of paper, check Field 10 onthe treatment form to indicate there areother attachments. Note in Field 34 thatwritten comments are attached.Written narrative documentation must belegible; printed or typewrittendocumentation is always preferred. Avoidstrikeovers, erasures or using correction fluidwhen printing or typing narrativedocumentation on the treatment form (Field34).If submitting electronically, abbreviatecomments to make optimum use of allottedspace.

Fill in each field as follows:

1.2.3.4.

5.

PATIENT NAME: Enter the beneficiarys last

name, first name and middle initial.Field removed.PATIENT SEX: Check M for male or F forfemale.PATIENT BIRTHDATE: Enter the beneficiary'sbirthdate (mmddyy). The birthdate is used tohelp identify the beneficiary. Differencesbetween the birthdate on the Medi-CalIdentification Card and the birthdate given by thebeneficiary should be brought to the attention ofthe beneficiary for correction by his/her C